Consent to Transfer Records
Jennifer Hewko, Registered Midwife
3799 Avonlea Drive, Nanaimo, BC V9T 6R1
Phone/Fax (250) 760-1080
Lillian Sly, Registered Midwife
2506 Maxey Road, Nanaimo, BC V9S 5V6
Phone/Fax: (250) 741-1294
To:
Health Care Provider: ___________________________________
Phone/FAX: _______________________
From:
Client Name: ____________________________________________ Date of Birth: _____________________
PHN: _____________________ Past Pregnancy: YES ____ NO ____
I, _____________________________________ am requesting midwifery care during this pregnancy and birth. Please fax a copy of all pertinent records (prenatal records, lab reports, ultrasounds, and birth summaries any previous pregnancies to the number listed above. I hereby authorize the release of my records as listed above to ___________________________________.
Signature: ___________________________________
Date: _____________________
If _____________________________________ is accepted into midwifery services, her maternity care will continue until the sixth week postpartum. At that time, copies of prenatal and/or birth records can be forwarded on request. In the event that concerns develop outside the scope of midwifery practice guidelines, consultation, or transfer of care will occur as set forth by the College of Midwives of British Columbia.
Thank you,
Jennifer Hewko, RM
Lillian Sly, RM