The physicians and midwives of the Faculty Obstetrics and Gynecology Group (“FOGG”) recognize that some women plan to have their babies at home. Although FOGG does not endorse home birth, we will provide prenatal and intrapartum services as described below to women planning home birth .

1.      I understand that FOGG does not endorse home birth and does not have a professional
          relationship with a home birth practitioner to provide back-up medical services for home birth.

2.      I understand that FOGG will not discuss my case via telephone nor offer any phone consultation with my home birth practitioner.  However, I understand that I may call FOGG directly with any questions I may have during my pregnancy.  

3.      I understand that the physician and midwife members of FOGG will not provide care for me at home.

4.      I understand that at my request, FOGG will provide prenatal or delivery services to me at UCSF Stanford Health Care and that I may call with questions or concerns at any time.  I have been told that at a minimum, FOGG recommends an initial visit as soon as I think I am pregnant and a visit when I am 36 weeks pregnant with the FOGG practice if I am receiving prenatal services from a home birth practitioner as well.  

5.       I understand that whether or not I utilize any prenatal services,  I may come to the hospital to deliver my baby, and neither FOGG nor UCSF Stanford Health Care will turn me away . 

6.       I understand that if my baby is delivered at the hospital, my home birth practitioner is welcome to accompany me and support me through my labor, but cannot  function as a health care provider or make decisions about my care.

7.       I understand that UCSF Stanford Health Care is a teaching hospital, and FOGG physicians and midwives may be assisted by medical students, interns, residents and fellows in providing my care.

8.       I have read and understand every paragraph above, and I agree to the stated conditions.  All my questions have been answered to my satisfaction. 

 Patient Signature

__________________________________Witness        Date _________________