Maternity admission forms

Congratulations and thank you for choosing to give birth to your

baby at The Bays.

To ensure a smooth booking process, please read the following information carefully.

Please complete all the enclosed forms and phone the hospital on 5975 2009 to book
an interview appointment with one of our midwives. During your appointment the
midwife will review your documentation with you, inform you about the admission
process and answer any other questions you may have.

Financial information is overleaf.

On your admission day, make sure you bring all of your current medications with
you in their original packaging. If you have a medication list from your local doctor
please bring this with you too.

Maternity unit tours are available on Sundays at 3pm to 3.30pm (excluding

public holidays). Bookings are essential. If you and your family would like to
attend please phone the hospital in advance or you can book a tour on our
website.

Please ensure that you read the patient and maternity information
brochures enclosed and further information is available at
www.thebays.com.au

To book your interview appointment phone us on 03 5975 2009

The Bays Hospital

Vale Street | PO Box 483
Mornington VIC 3931
Phone 03 5975 2009
Fax 03 5975 2373
ABN 35 146 117 211 | www.thebays.com.au
Maternity services financial information
Patients with private health insurance
Please ensure you contact your Health Fund to verify your membership entitlements,
i.e. all waiting periods served and no exclusions apply on your policy.
A health fund excess may apply which is payable on admission.
Health fund excess may also apply if your baby needs any additional care requiring
admission into the Special Care Nursery. Ensure your baby is covered and if an
excess is applicable.
The cost of ambulance transfer to another hospital is your responsibility and
we recommend you have ambulance cover for yourself and your baby.

Patients without private health insurance and medicare ineligible patients

If you elect to self-fund your stay in hospital there will be fees payable for:
• Birthing suite or theatre fee for Caesarean Section
• Private room fee per day
• Special Care Nursery (if baby needs admission) per day
• Doctor’s fees are separate to any hospital costs.
Please call 03 5975 2009 for a quote and fee estimation.
A deposit of $100 is payable at the time of booking and full payment is required at
least one month prior to your expected birthing date. An instalment plan can be
arranged if required. There is a cancellation fee of $50.
Ambulance charges apply to yourself and your baby and are not the responsibility
of The Bays Hospital.

Childbirth sessions
Childbirth sessions are available to all couples booked into The Bays. These are
covered by your health fund and are available either on two consecutive
Sundays from 1-5pm or four Monday evenings from 7-9pm for first time parents.
Session dates will be organised on the day of booking in with the midwife.
For self-funded couples the cost is payable per couple per group of
sessions. Please call 03 5975 2009 for a quote and fee estimation.

Special Care Nursery

The Bays Hospital has a special care nursery for babies who are premature, unwell
or have more complex care needs. It is important that you check your health
insurance as many single memberships do not cover newborn babies. If not covered,
please call 03 5975 2009 for a quote and fee estimation.
 UR NUMBER 123456789

SURNAME Mr. Sugih Sp.d and Mr.s Wati

The Bays Healthcare Group Inc
GIVEN NAMES -
OBSTETRIC BOOKING DATE OF BIRTH SEX -
FORM Please fill in if no Patient Label available

PLEASE COMPLETE BOTH SIDES & BRING BACK TO HOSPITAL WHEN BOOKING IN
Booking in Date: 20 February 2021 Midwife booking in (Please print): 20 February
2021
Name: Mr.s Wati First day of last menstrual period: 23 November
2021
Partner: Mr. Sugih Sp.d Due date by menstrual date / ultrasound:
Obstetrician: Blood Pressure: 110/60
Date of 1st visit: Gestation:1st Card sighted: Yes
20February202
1
Allergies: (e.g. Drugs, Bandaids, Foods) Pre Pregnancy weight:
Height: 160 CM
Reaction: no BMI: 60Kg
Please include all details of previous pregnancies, including miscarriages

GRAVIDA: PARITY:
DO NOT WRITE IN MARGIN

No. Of Type of Birth Lengt Complications Breast Health

of child
Date weeks of Hospital (Vaginal/Forceps/ h of (eg. Reason for Sex Weight fed Name
pregnancy Caesarean) Labour caesarean) yes/no of child
- - - - - - - - - -

Do You have history of:

Heart disease / Rheumatic Fever No High blood pressure No O
Kidney disease No Lung disease (e.g. TB) No B
Epilepsy No Blood Transfusion No S
Asthma No Hepatitis / Jaundice No
T
E
Disorder of nervous system ie MS No Assault (physical/psychological) No
Blood disorders (e.g. anaemia,
T
No No
Diabetes
thalassaemia) RI
Psychiatric Illness/depression/anxiety No Hormone problems (e.g. thyroid) No C
Infertility No Muscle / bone problems No B
Do you smoke? No No
O
Does your partner smoke?
How many cigarettes per day (-) Was QUIT information discussed? No

If ceased smoking, when? (-) Alcohol consumption No

(Please circle) (-) How many glasses per week (8x7)

CPFEB2017

Current rubella immunisation No

Substance Use No
Level
M
(-) R/
Have you had a fall in the last 6 months No 2
8
If yes to any of the above, please specify: (-)
 UR NUMBER

SURNAME

The Bays Healthcare Group Inc GIVEN NAMES

DATE OF BIRTH SEX

OBSTETRIC BOOKING FORM Please fill in if no Patient Label available

Do you have a family history of:

Twins No Genetic Disorders No
High blood pressure No Diabetes No
Aboriginal status of baby No
If yes to any of the boxes above, please specify: (-)

Do you have any other medical illnesses (i.e. Crohn’s Disease, eczema, disability, deafness, blindness, etc.)?
NO
Do you have gynaecological history (i.e. Cervical dysplasia, herpes, etc.)?
NO
Have you previously had an operation? If so, please state what and when.
NO

Did you experience any problem with anaesthetic?

NO
Are you on any medication? If so, please name and specify dosage.
NO D
Have you had depression during pregnancy or post pregnancy? O
YES N
O
Edinburgh score for this pregnancy: - Weeks G estation: 12 Weeks
Are you well so far in this pregnancy? If not why?
T
Yes, my pregnancies is nice W
Investigations/Procedures:- RI
Ultrasound No T
If yes, How many weeks: E
CVS No Amniocentesis No
IN
Non Invasive Perinatal
No Other Procedures (e.g. IV) No
M
Testing (NIPT) A
Please specify if yes to other procedures:
NO

Conditions developed during pregnancy:

Verry Good
Plan for vaginal birth after a previous caesarean? No

Do you intend to have ante natal classes? No

CREUTZFELDT – JAKOB DISEASE (CJD) QUESTIONNAIRE
1. Have you suffered from a recent rapid progressive dementia, physical or mental, the cause
of which has not been diagnosed? No
2. Do you have a family history of 2 or more first-degree relatives with CJD or other undiagnosed
neurological illness? No
3. Have you received human pituitary- derived gonadotrophin (for infertility) or growth hormone
(for short stature)? No
4. Have you received a dura mater graft in a neurological or other surgical procedure before 1990? No
5. Have been involved in a CJD look back? No
6. Do you have a “Medical in Confidence” letter in regard to your risk of CJD? No
If you have answered yes to any of the above CJD questions, please contact
The Bays Hospital Supervisor on 5976 5251 prior to your admission date

PATIENT’S SIGNATURE: WATI

Midwife’s Signature:  Midwife’s Name: RAHAYU NIDA M, STr Keb