S-0.1, r. 14 - Regulation respecting the standards and conditions of practice for conducting home deliveries

Schedule Disposition versions

2012-09-01

SCHEDULE I

(s. 2)

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) ________________

Signature: ________________________

________________________

Name of midwife: ________________________

Licence number: ________________________

O.C. 456-2004, sch. I.