Patient Registration - Birthcare Auckland

We are delighted that you are considering birthing and/or having your postnatal stay with us.

Please complete this form if you have an LMC caring for you during your pregnancy. If you do not yet have an LMC and would like to birth with us please send an us an email.

PERSONAL DETAILS

Your first name*

Your surname*

NHI number (optional) 'ABC1234'

Your date of birth*

Address*

Address 2

Suburb*

City*

Postcode

Mobile number*

Alternative number

Email*

If you were not born in New Zealand – copies of your passport will have to be provided showing residency status

Country of Birth*

Occupation (optional)

Mother Ethnicity*

Baby Ethnicity*

Do you need an interpreter?

Yes No

Special Dietary Needs / Allergies

Drug Allergies

Do you have health insurance?*

If Yes – which insurance company?

Yes No

If Yes – Is your medical insurance a private or corporate membership?

BIRTHCARE SERVICE SELECTION Please refer to Birthcare's Schedule of Charges for full pricing information as you must meet certain criteria for our free services.

Are you a NZ resident?*

Yes No

Birthcare Options for NZ Residents

Labour, Birth and Postnatal Stay
NOTE: Birthcare only provides facilities for normal labour and birth.
Postnatal Stay Only

Room Options (conditions apply, please see our schedule of charges)
Premium Room (if available)
Private Room
Shared Room

Labour and Birth Only

Additional Comments/Requirements (optional)

SCHEDULE OF CHARGES

I have read and agree to Birthcare's Schedule of Charges *

LEAD MATERNITY CARER

Lead Maternity Carer Type *

Lead Maternity Carer First Name*

Lead Maternity Carer Surname *

Name of Postnatal Midwife

Expected due date *

Proposed Place of Birth*

Gravida (number of pregnancies you have had including this pregnancy) *

Parity (number of babies previously born) *

NEXT OF KIN OR CONTACT PERSON

First Name *

Surname *

Relationship to you

Their phone number *

Alternative contact number

Their address

Please ask your LMC if you need help completing the information below.
BLOOD INFORMATION

Blood Group *

Rhesus *

Hepatitis B *

MEDICAL HISTORY

Do you have any Medical history?*

BMI Please consult with your midwife for this information.

Please ask your LMC if Birthcare is the most appropriate place for you to birth.

OBSTETRIC RECORD (Based on Gravida Number entered above)

CODE OF RIGHTS / TERMS & CONDITIONS

I have read and agree to the Code of Rights and Birthcare’s Terms and conditions *

Birthcare Auckland provides antenatal, breastfeeding, and refresher classes. To book online please visit our Classes to choose your preferred education.
Please refer to the 'Classes' menu option on www.birthcare.co.nz for further details.