CONSENT TO SERVICES OF A MIDWIFE FOR HOME BIRTH
I, the undersigned, ______________________________, have decided to give birth at home, at ______________________________ and be accompanied by a midwife.
I acknowledge having been informed of the following:
· the particularities of different places of birth, the advantages and risks related thereto;
· measures related to home birth;
· cases in which consultation with a physician or transfer of clinical responsibility to a physician is required;
· emergency measures to be taken if there is a complication;
· criteria for transportation from the home to the hospital centre where indicated, including the distance involved.
I hereby understand that the planning of a home birth does not guarantee that I will give birth at home.
I hereby understand that I can change my choice of the birthplace at any time.
In witness whereof I have signed: at (municipality) __________
this (date) ________________
Name of midwife: ________________________
Licence number: ________________________