Congratulations on your new baby!

Please complete our Newborn Information Form if you've just had a baby at Burnside Hospital or Calvary North Adelaide Hospital and have been seen by one of our paediatricians.

Newborn Information Form

Paediatrician

Hospital

Newborn Details

Name

As it will be written on the birth certificate and Medicare card. If you haven't named your baby yet, please write 'Baby' as the first name, and the surname you plan to give (or at least one of the parent surnames!)

First Name

Last Name

Middle Name

Known As

If your baby will be known by a different name or nickname

Date of Birth

Sex

Home Phone

Best Email

Postal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Residential Address

If different from postal address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Account Holder Details

This is the person who will be responsible for the account and receive any Medicare rebates. The Account Holder can be changed if needed. It is usually the person who frequently organises and comes to appointments.

Name

First Name

Last Name

Relation to Patient

Date of Birth

Gender

Mobile Phone

Other Parent or Alternate Next of Kin Details

Name

First Name

Last Name

Relation to Patient

Date of Birth

Gender

Mobile Phone

Patient's Medicare Details

Whose Medicare card will baby be added to?

Reference Number

What number is baby likely to be on the Medicare card?

Account Holder Medicare Details

Medicare Number

Reference Number

Number next to account holder's name on card

Expiry

Other Parent/NOK Medicare Details

Medicare Number

Reference Number

Number next to Other Parent/NOK on card

Expiry

Other Details

If applicable/known

Private Health Insurance

Please provide the details of the policy baby will be added to. If you haven't yet registered your baby at your fund, please do so as soon as possible, in case your baby needs to be admitted to the nursery.

Fund Name

Membership Number

Patient's Reference Number

What number will baby be on the card?

Languages other than English

Language of parents if not English

Interpreter Needed?

Obstetrician

Which obstetrician was present at your delivery?

Obstetrician's Name

Usual GP

Please provide the GP or clinic you plan to take baby to. This is likely to be your existing usual GP/clinic.

Preferred GP's Name

Clinic Details

Agreement

I have read and agree to the following policies:

I have read and agree to the privacy policy.

I have read and agree to the bookings, fees and cancellations policy.

I would like another copy of the paediatrician's information sheet.

Your baby’s six-eight week check-up:

Has your paediatrician advised you of a booking for this appointment?

Or do your need to organise it?

Contact our receptionists to make an appointment or change.

Please also ensure you read our privacy policy and bookings, fees and cancellations policy prior to completing this form.

Newborn Information

Congratulations on your new baby!

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