Healthcare Women and Infants Consent Form

Healthcare Women and Infants Consent Form

Patient Information

Date of Birth:    Gender:    Preferred Language:

Phone:    Alternate Phone:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:    Subscriber Name:

Obstetric and Medical History

Gravidity (G):    Parity (P):    Prior Cesarean:    Prior Preterm Birth:

Estimated Delivery Date:    Obstetric Provider:

Consent for Maternal Treatment

I, the undersigned patient, authorize physicians, midwives, nurses and other authorized health care personnel to provide routine and emergency obstetric care related to my pregnancy, labor, delivery and immediate postpartum care. I acknowledge that no guarantee has been made as to the results of any treatment or procedure. I understand benefits include monitoring and treatment to reduce maternal and fetal morbidity and mortality; risks include but are not limited to infection, bleeding, allergic reaction, anesthesia-related events, and unforeseen complications.

I specifically consent to the following as needed for my care:

General obstetric care, examinations, monitoring and medications.

Administration of regional or general anesthesia as deemed necessary by the anesthesia team.

Blood transfusion, blood products or blood-saving interventions when clinically indicated.

I understand the right to refuse any intervention and the right to ask questions prior to treatment; however, I acknowledge that in instances where refusal places me or my infant at immediate risk, the clinical team may implement emergent treatment aimed at preserving life or preventing serious harm.

Consent for Newborn Care and Procedures

I authorize routine newborn care for my infant, including clinical examinations, measurements, monitoring, and interventions commonly performed as part of newborn care. I understand that some procedures are time-sensitive for the health of my child.

Routine newborn care and assessment (physical exam, measurements, thermoregulation).

Vitamin K injection to prevent hemorrhagic disease of the newborn.

Prophylactic ocular medication (eye ointment) to prevent neonatal eye infection.

Newborn hearing screening.

Newborn metabolic and screening tests (heel-stick blood spot).

Hepatitis B vaccine for the newborn (first dose).

Photographs for medical record and identification purposes.

Emergency resuscitation and stabilization of the newborn as clinically required.

I consent to circumcision if indicated and requested. If consented, I understand a separate procedure-specific consent and scheduling may be required.

Privacy, Authorization, and Expiration

I acknowledge receipt of the facility's privacy notice and understand that my medical information, and that of my infant, may be used for treatment, payment and health care operations. I authorize disclosure of protected health information to persons and agencies involved in my care and the care of my infant, as reasonably needed.

I acknowledge I have been provided access to the privacy notice and authorize disclosure as described above.

Additional Information / Declinations

Certification and Acknowledgment

By signing below, I certify that I am the patient or the legally authorized representative of the patient. I have read (or had read to me) and understand the information provided above, including the nature, purpose, risks and benefits of the proposed care and procedures. I have had the opportunity to ask questions and understand I may withdraw this consent at any time except to the extent that action has already been taken in reliance on this consent.

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