h Disclosure and Informed Consent Form f


______1. I am aware that the practices of medicine, nursing and midwifery have some similarity but are distinctly different, that no healthcare or medical discipline is an exact science and I acknowledge that no guarantees can be make to me concerning the results of midwifery care provided to me, my unborn or newborn baby. 


______2. General Permission for Hands-on Care & Exams:  

I authorize Faith Gibson, LM and her assistants to perform, according to their training and expertise, physical exams on me to confirm general health and pregnancy status, obtain laboratory specimens and assess the condition of my fetus via palpation of my uterus and listening to fetal heart tones. Furthermore, I understand that I may decline standard midwifery care or withdraw my consent for routine treatment at any time. Invasive procedures, including routine vaginal exams, are to be done only with my express permission, given at the time that care is being rendered.


_______3. Additional Informed Consent Conversations & Documentation will be provided to me relative to medical interface and emergency plans, GBS protocols, labor & birth at home and any decline of standard midwifery care, medical referral or advice or other special circumstance wavier of care.


 ______4. Right of Client to withdraw from Care / Right of Midwife to Terminate Care: I understand that I may withdraw from midwifery care at any point and that my midwife may terminate her caregiver relationship with me by providing 14 days written notice so that I may make alternative arrangements. 


_______5. Assistants and Associates:  I understand that other people besides Faith Gibson, LM may be involved in my care, including but not limited to an assistant or midwifery student, consulting physicians/ midwives, birth assistants of your choice and other midwifery colleagues (such as a 2nd call midwife)


_______6. Client Agreement: I have read the Disclosure and Informed Consent for New Clients. My questions have been satisfactorily answered. I understand and accept the conditions for my care as presented in this document and in conversation with my midwife.


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            Signature of Client                                             date

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            Signature of Partner                                            date

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            Signature of midwife                                         date