Informed Consent – Recommendation to Consult with a Physician

In accordance with Idaho State Law, we recommend that clients with any of the following conditions see a physician.

• Previous complicated pregnancy
  
• Previous cesarean section
  
• Previous pregnancy loss in second or third trimester
  
• Previous spontaneous premature labor
  
• Previous preterm rupture of membranes
  
• Previous preeclampsia
  
• Previous hypertensive disease of pregnancy
  
• Parvovirus
  
• Toxoplasmosis
  
• Cytomegalovirus
  
• Herpes simplex virus (HSV)
  
• Previous maternal/newborn group B streptococcus (GBS) infection
  
• A body mass index of at least thirty-five (35.0) but less than forty (40.0) at the time of conception
  
• Underlying family genetic disorders with potential for transmission
  
• Psychosocial situations that may complicate pregnancy
  

It has been recommended to us that we should see a physician before proceeding with plans to have an out of hospital birth if we have or have had any of the above conditions.  I have read the above conditions.

Client’ Signature____________________________________________________Date_______________