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Birthday
Day
Month
Year
Last Menstraul Date (If Known)
Day
Month
Year
Estimated Due Date (If Known)
Day
Month
Year
Birth Type Planned
Vaginal
Ceasarean Section
VBAC
Uncertain
Number Of Prgnancies Including Current
Number Of Live Children Born
Number Of Misscairrages
Number Of Terminations
Number of Vaginal Birth(s)
Any Babies Born Before 37 Weeks?
Yes
No
N/A
History of Gestational Diabetes?
Yes
No
N/A
History Of PET/Hypertention?
Yes
No
N/A
Planning To Breastfeed?
Yes
No
Have You Had Any Vaccinations In The Last 12 Months/
Yes
No
Current/History Of The Following Conditions
Dating UltraSound
Queensland X-Ray
North Queensland X-Ray
I-Med
Focus
Cairns Hospital
N/A
Other
12 Week/Nuchal Ultrasound
Queensland X-Ray
North Queensland X-Ray
I-Med
Focus
Cairns Hospital
N/A
Other
20 Week/Morphology Ultrasound
Queensland X-Ray
North Queensland X-Ray
I-Med
Focus
Cairns Hospital
N/A
Other
Smoking:
Never Smoked
Ceased smoking upon falling pregnant
Smokes tobacco
Smokes 'Weed'
Partner smokes
No-one in the household smokes
Other
Blood Clots (DVT):
No History
Factor V-Leyden
Compression stockings (TEDS)
Daily Aspirin
Clexane
Other
Domestic Violence:
Nil concerns
Current
History of DV
Mental health:
Nil concerns
Anxiety
Depression
Postnatal Depression
Other
Bladder Function:
Normal
Recurring UTI's
Frequency
Urgency
Dysuria
Voiding difficulties
Incontinence
Stress Incontinence
Urgency
Other
Bowel Function:
Pelvic Floor & `Physiotherapy' (current or past):
Leboratory Tests

The Consent and Management Agreement can be viewed here:

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Product
Management Fee A — A$1350
Management Fee B — A$750
Management Fee C — A$450

Please note that after submittion you will recieve an email with the relevant document that you need to sign in order to complete your application. The email will arrive within 10-60 seconds.

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