I/We wish to engage ________________________________________________________ from Community Midwifery Services as my Primary midwife.
And for, ___________________________________________________________________ , to provide midwifery care for my/our homebirth/hospital birth. (Please circle agreed option)
Options for the safe birth of our child have been explained to us by ___________________ and we understand the advantages and disadvantages of our chosen place of birth, and consequently I/ we are willing to take full responsibility for our decision.
I/We agree to hospitalization/specialist obstetric care in the event of complications or on the advice of our midwife.
_______________________________________has informed me/us that Midwives in Australia do not have access to Medical Indemnity Insurance, and therefore I/we are aware that there is no insurance company to claim against.
If at anytime I/we decide to not to accept the advice of our midwife during pregnancy, birth or the postnatal period, then the full responsibility of the health of the mother and child will be mine/ours.
And I/we also agree to release _____________________________and her assistants financially in relation to all claims or actions including legal costs arising out of, or caused by my pregnancy, the birth, the services, or the advice.
A total fee of $________________________ has been agreed for the midwifery services. I /We agree to pay the full amount two weeks prior to the expected date of birth in the manner agreed upon.
Cancellation of midwifery services during the prenatal period (before 34 weeks) will incur a settlement fee of $200 in addition to the midwifery services given thus far. If cancellation occurs after 34 completed weeks of pregnancy, the full fee is payable.