Informed Consent – Conditions Requiring Co-Managed Physician’s Care

I understand that an Idaho Licensed Midwife is prohibited from providing care for a client with a history of the following disorders, diagnoses, conditions or symptoms unless such disorders, diagnoses, conditions or symptoms are being treated, monitored or managed by a physician.

Current history of:

• Diabetes

• Epilepsy

• Hypertension

• Abnormal cervical cytology

• Hepatitis

• Sleep apnea

• History of illegal drug use or excessive prescription drug use

Past history of:

• Previous bariatric surgery

• Previous major surgery of the pulmonary system, cardiovascular system, urinary tract or gastrointestinal system

 Current or past history of:

• Cardiac disease

• Pulmonary disease

• Renal disease 

• Gastrointestinal disorders

Client’s Signature___________________________________________ Date_________________