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 _________________