APPLICATION FOR FULL OBSTETRIC CARE

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you had a child? *

Yes

No

If yes, what was your mode of delivery

Vaginal

Caesarean

Have you had a prior delivery with Wellington Obstetrics? *

Yes

No

What is your intended mode of delivery this pregnancy? *

(NB: for balanced numbers)

Vaginal

Caesarean

Unsure

Have you been referred by your GP, Fertility Specialists or other Doctor? *

Yes

No

Please enter you estimated due date based on your dating scan *

MM

DD

YYYY

Please select where your dating scan was performed *

Wellington Ultrasound

Pacific Radiology

Wellington Hospital

Fertility Associates

Wellington Imaging

Valley Ultrasound

Sharp Ultrasound

Affinity Medical Imaging

Other

Date of scan *

MM

DD

YYYY

To determine the fees payable we need to confirm if you are eligible to publicly funded health & disability services. Please select the category that applies to you. (NB proof of eligibility will be requested by our medical administrators for your hospital booking)

NZ Citizen

NZ Resident

Australian Citizen or Resident staying in NZ for 2 years or more

Work visa holder for two years or more

Other

Non-eligible (eg Diplomat, non-resident, tourist visa holder etc)