RPA First Antenatal Visit Appointment Form

Personal Details

Surname: *

Given Name(s): *

Previous or Maiden Name:

Street Address: *

Suburb:*

State:*

Postcode:*

Phone (H):

Phone(W):

Mobile:*

Contact Email: *

Date of birth: *

Age: *

Will the baby identify as Aboriginal or Torres Strait Islander? * :

Yes No

Do you require an Interpreter? * :

Yes No

If yes please specify

Alternate Contact Person

Surname: *

Given Name(s): *

Relationship: *

Street Address: *

Suburb:*

State:*

Postcode:*

Contact No:*

Clinical Details

Which of the following Models of Care would you like to follow? * :

Hospital-Based Care

Hospital-based care

Hospital-based care means that your care is provided primarily by midwives at RPA, with more doctor visits organised if you need them.

GP Shared Care

Pregnancy care shared between a general practitioner who is recognised by the GP Antenatal Shared Care Program and the Antenatal Clinic Midwife or Birth Centre Midwife (RPA only). This model of pregnancy care is offered to women in good general health with a low risk pregnancy - determined at the first antenatal visit.

Birth Centre

(Phone Bookings Only: 9515 6405)
Midwifery Group Practice

(Phone Bookings Only: 9515 8864)

Midwifery Group Practice

The Midwifery Group Practice is a team of midwives who support a philosophy that pregnancy and childbirth are normal healthy life events. One of the midwives in the group will be allocated to care for you throughout your pregnancy and you will have the opportunity to meet the other midwives who may care for you during your labour and birth. After your baby is born you will be able to return home as soon as possible with the support of the Midwifery Group for up to two weeks postnatal.

To book with the MGP or for further enquiries please call 9515 8864 and leave your contact details for one of the midwives to call you back.

Please discuss this option with your midwife at your 1st Booking Appointment

Please call 02 9515 6054 to book into the Birth Centre – please do not complete the online booking form

Please call 02 9515 8864 to book with the Midwifery Group Practice - please do not complete the online booking form

Are you covered by Medicare? * :

Yes No

Medicare Number *

Do you have a Private Health Insurer? *

Yes No

Fund Name

Fund Member no

Do you have a Shared Care GP? *

Yes No

GP Details*:

GP Practice Address*:

GP Contact Number*:

How many weeks pregnant? *

Estimated Date of Confinement:

Have you attended this hospital before?:*

Yes No

Have you previously received pregnancy care at RPA?:*

Yes No

Have you booked/already completed your 12-13 weeks scan? * :

Yes No

Date:

Where/Facility

Please speak to your GP regarding the Nuchal Translucency Scan

Any current or previous medical conditions?*

Yes No

If there are current or previous medical or pregnancy concerns a GP Referral MUST be attached to this application in order for an appointment to be made

Any current or previous pregnancy issues?*

Yes No

If there are current or previous medical or pregnancy concerns a GP Referral MUST be attached to this application in order for an appointment to be made

Do you have a GP Referral? * :

Yes No

Upload/Attach a GP referral - as PDF:
Please make sure that your attached file do
NOT include any special character (! + ( ) , * etc.)

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