Name *

Full name as it appears on your Medicare card

First Name

Last Name

Phone number *

We will call you on this number if we have any issues with our video consult

Country

(###)

###

####

Address *

The current address where you are living

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your date of birth *

MM

DD

YYYY

I acknowledge that the hospital listed above is the hospital that my midwife will ask me to attend if this becomes necessary as per the National Midwifery Guidelines for Consultation and Referral. *

I understand

Are you booking this appointment for yourself? *

Yes, this appointment is for me

No, this appointment is for someone else

Are you currently: *

Pregnant

I've given birth and my baby is less than 6 weeks old

If you are pregnant - what is your due date? If you've given birth - what date did you give birth? *

MM

DD

YYYY

I agree to the terms and conditions, provide informed financial consent and consent for care via telephone or telehealth *

I ACCEPT

I assign my right to Medicare benefits to the midwife who renders my service (this means I agree to my appointment being bulk-billed through Medicare) *

I agree