Columbus County
HEALTH DEPARTMENT
Kimberly L. Smith, RN, BSN, MSHCA, Health Director
PO Box 810
Whiteville, NC 28472
304 Jefferson Street
Tele: 910-640-6615
Fax: 910-640-1088
Maternity Clinic Consent Form
I, _________________________________ hereby request the complete service of the Columbus County Health Department Maternity
Clinic. I agree to give accurate information regarding residency, income, maternity insurance, pregnancy, name, age and marital status, as
needed by the Department of Social Services for certification. I also agree to give accurate information of the baby’s father, the person
most responsible for my medical and pregnancy history, and such other information as needed by the Health Department and any
participating hospital. Anytime this information changes, I will let the Health Department know.
The Health Department is authorized to perform any and all tests needed to ensure the best health of myself and my baby. These tests
will include pregnancy, rubella, STS,(every woman is required by law to have a blood sample to determine whether she has syphilis),
urinalysis, urine culture, hemoglobin, ppd, Chlamydia test, CBC and blood type, and RH factor, sickle cell test , RH antibody titer, AFP,
blood sugar, pap smear, group B strep and gonorrhea culture, blood lead screening and potential testing during pregnancy if the
client screens positive. HIV testing will be done on the initial visit and repeated during the third trimester. I understand that some of
these tests will be repeated occasionally throughout my pregnancy.
I consent to a complete physical at my first visit after verification of pregnancy, which will include a pelvic exam with the above
mentioned tests and other tests as decided by the MD or the practitioner. A non-stress test may be done as indicated.
I will agree to seen by the nutritionist, home economist as indicated.
I will authorize medical treatment by any aide, licensed practical nurse, registered nurse, nurse practitioner, nurse midwife, or doctor
within the Health Department as needed to ensure the best health of myself and my baby. I also consent to any social worker, nutritionist,
home economist or secretary having a part in my care. I will make every attempt to keep my prenatal appointments, and will notify the
Health Department when I am unable to do so in order that a new appointment may be given.
As a patient, I have a right to privacy and know that what I say and my medical records are held in strict confidence. A minor must
consent to release of information about her pregnancy. Disclosure of pregnancy information on minors to parents is illegal unless in the
opinion of the physician that the health of the minor child or the unborn child is in danger. I hereby consent to the release of my Health
Department Prenatal record to Columbus Regional Health Care System and or New Hanover High Risk Clinic so that the hospital or
clinic staff can provide the best possible care for me during my labor and delivery. If addition referrals are needed a medical records
release form will be signed.
THIS CONSENT IS A CONTINUING CONSENT AND SHALL CONTINUE DURING THE TERM OF MY PREGNANCY OR
UNTIL EARLIER REVOKED BY ME IN WRITING. I HAVE READ AND UNDERSTAND THE TESTS.
**Prenatal Laboratory Informational Sheet given by (initials) ____________________.
This _________________________ day of _____________________, 20_____.
__________________________________
Witness (RN, CNM, or NP)
Rev 04/22/2015
___________________________________
Patient