Midwifery Consent Form

By completing this form, you will give your permission for a student midwife to participate in your care during your childbirth experience.

This means:

you will meet a first year student during your pregnancy, and they will follow you through pregnancy, labour, birth, and the early postnatal period.
that the role of the first year student will be that of a support person only.
the student will ask your permission before undertaking any procedure on your baby or yourself, and at such times they will be supervised by your midwife.
the student will visit you in your own home at times negotiated with you.
throughout the relationship, the student will be in close touch with their assigned lecturer.
you understand that all information shared will remain confidential and that neither your family nor you will be able to be identified in any written work.
you may discontinue the student's involvement in any part, or all of your care, at any time

A lecturer will be responsible for supervising your midwifery student and you can contact this person using the Polytechnic contact details below. The supervising lecturer will contact you for feedback about your experience with the student.

Midwifery School
Forth Street,
Private Bag 1910,
Dunedin, New Zealand
Telephone +64 3 479 3641 (Freephone: 0800 762 786)
Facsimile +64 3 474 1957

First Name *

Last Name *

Date *

Address *

Telephone *

Expected date of your baby's birth *

Name of your Lead Maternity Carer/Midwife *

Number of previous births *

Were these home-births or hospital-births?

If you know of a midwifery student and wish to have that student working with you, please indicate here:

If this student is no longer available, would you be happy to discuss having another student allocated to you?

Yes

Do you agree to allow non-identifying information from the student's notes being made available for use in assignments?

Yes