{"id":1879,"date":"2017-07-31T01:48:38","date_gmt":"2017-07-31T01:48:38","guid":{"rendered":"https:\/\/dev.metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/caboolture-hospital-antenatal-clinical-triage-form"},"modified":"2023-11-16T09:22:00","modified_gmt":"2023-11-15T23:22:00","slug":"antenatal-registration-form","status":"publish","type":"services","link":"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/antenatal-registration-form","title":{"rendered":"Antenatal online registration form"},"content":{"rendered":"","protected":false},"excerpt":{"rendered":"<p>Complete the Redcliffe Hospital antenatal form to ensure we have the most current information for your appointment. Once we receive your referral letter and your online registration, we will send you an appointment letter with your first appointment date.<\/p>\n","protected":false},"featured_media":0,"parent":0,"menu_order":0,"template":"","categories":[1],"tags":[18,502,866,958,982,1018,1126],"class_list":["post-1879","services","type-services","status-publish","hentry","category-uncategorized","tag-appointment","tag-pregnancy","tag-maternity","tag-online-registration","tag-antenatal-clinical-triage-form","tag-pregnant","tag-maternity-form"],"acf":{"page_subtitle":"","page_type":"general","page_sections_general":[],"accessing_this_service":[{"variation":"GP or medical practitioner referral","free_text":""}],"include_refer_a_patient_panel":true,"refer_a_patient_text":"","refer_a_patient_link":"","specialist_hotline":"1300 364 938","after_your_hospital_appointment":[{"variation":"Preadmission and surgery","free_text":""}],"general_content_0":false,"what_to_bring":[{"category":"general","what_to_bring_general":[{"display":[],"every_time":"","_copy":"","for_appointment":"","_copy2":"","for_procedure":"","_copy3":"","for_overnight":""}],"what_to_bring_mental_health":false,"what_to_bring_child_health":false}],"general_content":[{"other_content":[{"heading":"","content":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-padding-top:20px;--awb-padding-right:20px;--awb-padding-bottom:20px;--awb-padding-left:20px;--awb-bg-color:#f1f1f1;--awb-bg-color-hover:#f1f1f1;--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-1\"><h3 data-fontsize=\"21\" data-lineheight=\"26\">Collection notice<\/h3>\n<p>Queensland Health (QH) is required to manage your personal information in accordance with the Information Privacy Act 2009 and the Hospital and Health Boards Act 2011, Part 7 Confidentiality. QH is collecting the personal information on this form to assist in chart preparation for your pregnancy booking in visit and to assess your individual pregnancy health care needs. This form will be printed and filed in your patient medical record. Some of your personal information on your medical record may be given to carers, guardians or other government departments who provide associated services that require your information for the purpose of providing a health care service. Your information will be disclosed without your consent, if authorised or required by law. For further information about privacy and your health record please ask for a copy of the Queensland Health Privacy Brochure or visit <a href=\"http:\/\/www.health.qld.gov.au\/\">www.health.qld.gov.au<\/a>. <\/p>\n<\/div><div class=\"fusion-text fusion-text-2\"><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]&gt; *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_5' style='display:none'><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/redcliffe\/wp-json\/wp\/v2\/healthcare-services\/1879#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>4<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_25' style='width:25%;'><span>25%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_1\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Required fields are marked with an asterisk (<span class=\"gfield_required\" style=\"margin-left:0\">*<\/span>)<\/p>\n<p>It is imperative to contact your GP to obtain a referral to Redcliffe Hospital Antenatal Clinic. Please note completing this triage form is NOT in replacement of a referral from your GP.<\/p><\/li><li id=\"field_5_2\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Personal details<\/h3><\/li><li id=\"field_5_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name has_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_5_3'>\n                            <span id='input_5_3_2_container' class='name_prefix name_prefix_select gform-grid-col gform-grid-col--size-auto' >\n                                                    <select name='input_3.2' id='input_5_3_2'    aria-required='false'   >\n                          <option value=''>Title<\/option><option value='Mr.' >Mr.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Miss' >Miss<\/option><option value='Ms.' >Ms.<\/option><option value='Dr.' >Dr.<\/option><option value='Prof.' >Prof.<\/option><option value='Rev.' >Rev.<\/option>\n                      <\/select>\n                                                    <label for='input_5_3_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Prefix<\/label>\n                                                  <\/span>\n                            <span id='input_5_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_5_3_3' value=''   aria-required='true'   placeholder='First name'  \/>\n                                                    <label for='input_5_3_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_5_3_6' value=''   aria-required='true'   placeholder='Last name'  \/>\n                                                    <label for='input_5_3_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_4\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_4'>Previous family name (if applicable)<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_5_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_5\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div id='input_5_5' class='ginput_container ginput_complex gform-grid-row'><div class=\"clear-multi\">\n                                        <div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_5_5_2_container'>\n                                            <input type='number' maxlength='2' name='input_5[]' id='input_5_5_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_5_5_2' class='gform-field-label gform-field-label--type-sub '>DD<\/label>\n                                        <\/div><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_5_5_1_container'>\n                                        <input type='number' maxlength='2' name='input_5[]' id='input_5_5_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <label for='input_5_5_1' class='gform-field-label gform-field-label--type-sub '>MM<\/label>\n                                   <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_5_5_3_container'>\n                                        <input type='number' maxlength='4' name='input_5[]' id='input_5_5_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                        <label for='input_5_5_3' class='gform-field-label gform-field-label--type-sub '>YYYY<\/label>\n                                   <\/div>\n                                <\/div><\/div><\/li><li id=\"field_5_6\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_6'>Age<\/label><div class='ginput_container ginput_container_number'><input name='input_6' id='input_5_6' type='number' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_5_7\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>Country of birth<\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_5_7' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_5_8\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'>Marital status<\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_5_8' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Please select<\/option><option value='Married \/ De facto' >Married \/ De facto<\/option><option value='Never married' >Never married<\/option><option value='Widowed' >Widowed<\/option><option value='Seperated' >Seperated<\/option><option value='Divorced' >Divorced<\/option><\/select><\/div><\/li><li id=\"field_5_9\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_9'>What language do you speak at home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_5_9' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you require an interpreter?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_10'>\n\t\t\t<li class='gchoice gchoice_5_10_0'>\n\t\t\t\t<input name='input_10' type='radio' value='Yes'  id='choice_5_10_0'    \/>\n\t\t\t\t<label for='choice_5_10_0' id='label_5_10_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_10_1'>\n\t\t\t\t<input name='input_10' type='radio' value='No'  id='choice_5_10_1'    \/>\n\t\t\t\t<label for='choice_5_10_1' id='label_5_10_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_11\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'>For which language do you require an interpreter?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_5_11' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_12\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_12'>Religion<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_5_12' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_13\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a current Health Directive in place?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_13'>\n\t\t\t<li class='gchoice gchoice_5_13_0'>\n\t\t\t\t<input name='input_13' type='radio' value='Yes - please bring with you to your first hospital visit, a copy is required for our records'  id='choice_5_13_0'    \/>\n\t\t\t\t<label for='choice_5_13_0' id='label_5_13_0' class='gform-field-label gform-field-label--type-inline'>Yes - please bring with you to your first hospital visit, a copy is required for our records<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_13_1'>\n\t\t\t\t<input name='input_13' type='radio' value='No'  id='choice_5_13_1'    \/>\n\t\t\t\t<label for='choice_5_13_1' id='label_5_13_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you of Aboriginal and\/or Torres Strait Islander origin?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_14'>\n\t\t\t<li class='gchoice gchoice_5_14_0'>\n\t\t\t\t<input name='input_14' type='radio' value='No'  id='choice_5_14_0'    \/>\n\t\t\t\t<label for='choice_5_14_0' id='label_5_14_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_14_1'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes, Aboriginal'  id='choice_5_14_1'    \/>\n\t\t\t\t<label for='choice_5_14_1' id='label_5_14_1' class='gform-field-label gform-field-label--type-inline'>Yes, Aboriginal<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_14_2'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes, Torres Strait Islander'  id='choice_5_14_2'    \/>\n\t\t\t\t<label for='choice_5_14_2' id='label_5_14_2' class='gform-field-label gform-field-label--type-inline'>Yes, Torres Strait Islander<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_14_3'>\n\t\t\t\t<input name='input_14' type='radio' value='Yes, both Aboriginal and Torres Strait Islander'  id='choice_5_14_3'    \/>\n\t\t\t\t<label for='choice_5_14_3' id='label_5_14_3' class='gform-field-label gform-field-label--type-inline'>Yes, both Aboriginal and Torres Strait Islander<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_15\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Does the father of your baby identify as an Aboriginal or Torres Strait Islander?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_15'>\n\t\t\t<li class='gchoice gchoice_5_15_0'>\n\t\t\t\t<input name='input_15' type='radio' value='No'  id='choice_5_15_0'    \/>\n\t\t\t\t<label for='choice_5_15_0' id='label_5_15_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_15_1'>\n\t\t\t\t<input name='input_15' type='radio' value='Yes'  id='choice_5_15_1'    \/>\n\t\t\t\t<label for='choice_5_15_1' id='label_5_15_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you identify as an Australian South Sea Islander?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_16'>\n\t\t\t<li class='gchoice gchoice_5_16_0'>\n\t\t\t\t<input name='input_16' type='radio' value='Yes'  id='choice_5_16_0'    \/>\n\t\t\t\t<label for='choice_5_16_0' id='label_5_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_16_1'>\n\t\t\t\t<input name='input_16' type='radio' value='No'  id='choice_5_16_1'    \/>\n\t\t\t\t<label for='choice_5_16_1' id='label_5_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_170\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Does the father of your baby identify as an Australian South Sea Islander?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_170'>\n\t\t\t<li class='gchoice gchoice_5_170_0'>\n\t\t\t\t<input name='input_170' type='radio' value='Yes'  id='choice_5_170_0'    \/>\n\t\t\t\t<label for='choice_5_170_0' id='label_5_170_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_170_1'>\n\t\t\t\t<input name='input_170' type='radio' value='No'  id='choice_5_170_1'    \/>\n\t\t\t\t<label for='choice_5_170_1' id='label_5_170_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_18\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><i>Definition of Australian South Sea Islander: Australian born descendants of predominantly Melanesian people who were bought to QLD between 1863 and 1904 from eighty Pacific Islands, but primarily Vanuatu and Solomon Islands. <\/i><\/p><\/li><li id=\"field_5_19\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Contact details<\/h3><\/li><li id=\"field_5_20\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Home address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_5_20' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_20_1_container' >\n                                        <input type='text' name='input_20.1' id='input_5_20_1' value=''   placeholder='Street address' aria-required='true'    \/>\n                                        <label for='input_5_20_1' id='input_5_20_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_20_2_container' >\n                                        <input type='text' name='input_20.2' id='input_5_20_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_5_20_2' id='input_5_20_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_20_3_container' >\n                                    <input type='text' name='input_20.3' id='input_5_20_3' value=''   placeholder='Suburb' aria-required='true'    \/>\n                                    <label for='input_5_20_3' id='input_5_20_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Suburb<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_20.4' id='input_5_20_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_5_20_5_container' >\n                                    <input type='text' name='input_20.5' id='input_5_20_5' value=''   placeholder='Postcode' aria-required='true'    \/>\n                                    <label for='input_5_20_5' id='input_5_20_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_20.6' id='input_5_20_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_21\" class=\"gfield gfield--type-address field_sublabel_hidden_label gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Postal address<\/label><div class='gfield_description' id='gfield_description_5_21'>If different to home address<\/div>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip ginput_container_address gform-grid-row' id='input_5_21' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_21_1_container' >\n                                        <input type='text' name='input_21.1' id='input_5_21_1' value=''   placeholder='Street address' aria-required='false'    \/>\n                                        <label for='input_5_21_1' id='input_5_21_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_21_2_container' >\n                                        <input type='text' name='input_21.2' id='input_5_21_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_5_21_2' id='input_5_21_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_21_3_container' >\n                                    <input type='text' name='input_21.3' id='input_5_21_3' value=''   placeholder='Suburb' aria-required='false'    \/>\n                                    <label for='input_5_21_3' id='input_5_21_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Suburb<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_21.4' id='input_5_21_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_5_21_5_container' >\n                                    <input type='text' name='input_21.5' id='input_5_21_5' value=''   placeholder='Postcode' aria-required='false'    \/>\n                                    <label for='input_5_21_5' id='input_5_21_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Postcode<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_21.6' id='input_5_21_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_22\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_22'>Contact number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_22' id='input_5_22' type='tel' value='' class='small'  placeholder='Home, mobile or work' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_23\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_23'>Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_5_23' type='tel' value='' class='small'  placeholder='Home, mobile or work'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_24\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_24'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_24' id='input_5_24' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_171\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Would you like Redcliffe Hospital to contact you via text message regarding appointments and other information during your antenatal care?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_171'>\n\t\t\t<li class='gchoice gchoice_5_171_0'>\n\t\t\t\t<input name='input_171' type='radio' value='Yes'  id='choice_5_171_0'    \/>\n\t\t\t\t<label for='choice_5_171_0' id='label_5_171_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_171_1'>\n\t\t\t\t<input name='input_171' type='radio' value='No'  id='choice_5_171_1'    \/>\n\t\t\t\t<label for='choice_5_171_1' id='label_5_171_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_25\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Next of kin<\/h3><\/li><li id=\"field_5_27\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Next of kin: Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_27'>\n                            \n                            <span id='input_5_27_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.3' id='input_5_27_3' value=''   aria-required='true'   placeholder='First'  \/>\n                                                    <label for='input_5_27_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_27_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_27.6' id='input_5_27_6' value=''   aria-required='true'   placeholder='Last'  \/>\n                                                    <label for='input_5_27_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_28\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Next of kin: Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_28' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_28_1_container' >\n                                        <input type='text' name='input_28.1' id='input_5_28_1' value=''   placeholder='Street address' aria-required='true'    \/>\n                                        <label for='input_5_28_1' id='input_5_28_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_28_2_container' >\n                                        <input type='text' name='input_28.2' id='input_5_28_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_5_28_2' id='input_5_28_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_28_3_container' >\n                                    <input type='text' name='input_28.3' id='input_5_28_3' value=''   placeholder='Suburb' aria-required='true'    \/>\n                                    <label for='input_5_28_3' id='input_5_28_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_28_4_container' >\n                                        <input type='text' name='input_28.4' id='input_5_28_4' value=''     placeholder='State' aria-required='true'    \/>\n                                        <label for='input_5_28_4' id='input_5_28_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_28_5_container' >\n                                    <input type='text' name='input_28.5' id='input_5_28_5' value=''   placeholder='Postcode' aria-required='true'    \/>\n                                    <label for='input_5_28_5' id='input_5_28_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_28.6' id='input_5_28_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_29\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_29'>Next of kin: Contact number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_29' id='input_5_29' type='tel' value='' class='small'  placeholder='Home or mobile' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_30\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_30'>Next of kin: Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_30' id='input_5_30' type='tel' value='' class='small'  placeholder='Home or mobile'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_31\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_31'>Next of kin: Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_31' id='input_5_31' type='email' value='' class='small'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_5_32\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Additional contact person<\/h3><\/li><li id=\"field_5_33\" class=\"gfield gfield--type-name field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Additional contact person: Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_33'>\n                            \n                            <span id='input_5_33_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.3' id='input_5_33_3' value=''   aria-required='false'   placeholder='First'  \/>\n                                                    <label for='input_5_33_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_33_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_33.6' id='input_5_33_6' value=''   aria-required='false'   placeholder='Last'  \/>\n                                                    <label for='input_5_33_6' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_5_34\" class=\"gfield gfield--type-address field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Additional contact person: Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_34' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_34_1_container' >\n                                        <input type='text' name='input_34.1' id='input_5_34_1' value=''   placeholder='Street address' aria-required='false'    \/>\n                                        <label for='input_5_34_1' id='input_5_34_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_34_2_container' >\n                                        <input type='text' name='input_34.2' id='input_5_34_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_5_34_2' id='input_5_34_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_34_3_container' >\n                                    <input type='text' name='input_34.3' id='input_5_34_3' value=''   placeholder='Suburb' aria-required='false'    \/>\n                                    <label for='input_5_34_3' id='input_5_34_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_34_4_container' >\n                                        <input type='text' name='input_34.4' id='input_5_34_4' value=''     placeholder='State' aria-required='false'    \/>\n                                        <label for='input_5_34_4' id='input_5_34_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_34_5_container' >\n                                    <input type='text' name='input_34.5' id='input_5_34_5' value=''   placeholder='Postcode' aria-required='false'    \/>\n                                    <label for='input_5_34_5' id='input_5_34_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_34.6' id='input_5_34_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_35\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_35'>Additional contact person: Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_35' id='input_5_35' type='tel' value='' class='small'  placeholder='Home or mobile'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_36\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_36'>Additional contact person: Contact number<\/label><div class='ginput_container ginput_container_phone'><input name='input_36' id='input_5_36' type='tel' value='' class='small'  placeholder='Home or mobile'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_37\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_37'>Additional contact person: Relationship to you<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_5_37' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_38' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_5_2_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-38' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_39\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Medical details<\/h3><\/li><li id=\"field_5_40\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_40'>Medicare number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_40'>Do not include spaces in the number<\/div><div class='ginput_container ginput_container_text'><input name='input_40' id='input_5_40' type='text' value='' class='small'  aria-describedby=\"gfield_description_5_40\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_41\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_41'>Single digit next to your name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_5_41'>The number that appears before your name on the card<\/div><div class='ginput_container ginput_container_text'><input name='input_41' id='input_5_41' type='text' value='' class='small'  aria-describedby=\"gfield_description_5_41\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_42\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_42'>Medicare expiry date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_5_42' type='text' value='' class='small'    placeholder='mm\/yy' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_43\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>If you do not have Medicare, please note that fees may apply<\/p><\/li><li id=\"field_5_44\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Private health fund details<\/h3><\/li><li id=\"field_5_45\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have private health insurance<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_45'>\n\t\t\t<li class='gchoice gchoice_5_45_0'>\n\t\t\t\t<input name='input_45' type='radio' value='Yes'  id='choice_5_45_0'    \/>\n\t\t\t\t<label for='choice_5_45_0' id='label_5_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_45_1'>\n\t\t\t\t<input name='input_45' type='radio' value='No'  id='choice_5_45_1'    \/>\n\t\t\t\t<label for='choice_5_45_1' id='label_5_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_46\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_46'>Health fund<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_5_46' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_47\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_47'>Health fund membership number<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_5_47' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_48\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Details of entitlement cards<\/h3><\/li><li id=\"field_5_49\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a health card?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_49'>\n\t\t\t<li class='gchoice gchoice_5_49_0'>\n\t\t\t\t<input name='input_49' type='radio' value='Yes'  id='choice_5_49_0'    \/>\n\t\t\t\t<label for='choice_5_49_0' id='label_5_49_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_49_1'>\n\t\t\t\t<input name='input_49' type='radio' value='No'  id='choice_5_49_1'    \/>\n\t\t\t\t<label for='choice_5_49_1' id='label_5_49_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_50\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_50'>Health card number<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_5_50' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_51\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_51'>Health card expiry date<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_5_51' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_52\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a pension card?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_52'>\n\t\t\t<li class='gchoice gchoice_5_52_0'>\n\t\t\t\t<input name='input_52' type='radio' value='Yes'  id='choice_5_52_0'    \/>\n\t\t\t\t<label for='choice_5_52_0' id='label_5_52_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_52_1'>\n\t\t\t\t<input name='input_52' type='radio' value='No'  id='choice_5_52_1'    \/>\n\t\t\t\t<label for='choice_5_52_1' id='label_5_52_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_53\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_53'>Pension card number<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_5_53' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_55\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_55'>Pension card expiry date<\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_5_55' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_56\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have a Veteran&#039;s Affairs (DVA) card?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_56'>\n\t\t\t<li class='gchoice gchoice_5_56_0'>\n\t\t\t\t<input name='input_56' type='radio' value='Yes'  id='choice_5_56_0'    \/>\n\t\t\t\t<label for='choice_5_56_0' id='label_5_56_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_56_1'>\n\t\t\t\t<input name='input_56' type='radio' value='No'  id='choice_5_56_1'    \/>\n\t\t\t\t<label for='choice_5_56_1' id='label_5_56_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_57\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_57'>Veteran&#039;s Affairs card number<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_5_57' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_58\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_58'>Veteran&#039;s Affairs colour<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_5_58' type='text' value='' class='small'      aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_59' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_5_59' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_5_3_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-59' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_60\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>General practitioner details<\/h3><\/li><li id=\"field_5_61\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_61'>Name of your GP<\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_5_61' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_62\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_62'>Medical Centre<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_5_62' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_63\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_63'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_63' id='input_5_63' type='tel' value='' class='small'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_64\" class=\"gfield gfield--type-address field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_64' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_64_1_container' >\n                                        <input type='text' name='input_64.1' id='input_5_64_1' value=''   placeholder='Street address' aria-required='false'    \/>\n                                        <label for='input_5_64_1' id='input_5_64_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_64_2_container' >\n                                        <input type='text' name='input_64.2' id='input_5_64_2' value=''   placeholder='Address line 2'  aria-required='false'   \/>\n                                        <label for='input_5_64_2' id='input_5_64_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_64_3_container' >\n                                    <input type='text' name='input_64.3' id='input_5_64_3' value=''   placeholder='Suburb' aria-required='false'    \/>\n                                    <label for='input_5_64_3' id='input_5_64_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_64_4_container' >\n                                        <input type='text' name='input_64.4' id='input_5_64_4' value=''     placeholder='State' aria-required='false'    \/>\n                                        <label for='input_5_64_4' id='input_5_64_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_64_5_container' >\n                                    <input type='text' name='input_64.5' id='input_5_64_5' value=''   placeholder='Postcode' aria-required='false'    \/>\n                                    <label for='input_5_64_5' id='input_5_64_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_64.6' id='input_5_64_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_5_66\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_66'>Fax<\/label><div class='ginput_container ginput_container_phone'><input name='input_66' id='input_5_66' type='tel' value='' class='medium'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_67\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Antenatal booking information<\/h3><\/li><li id=\"field_5_73\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had a dating ultrasound scan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_73'>\n\t\t\t<li class='gchoice gchoice_5_73_0'>\n\t\t\t\t<input name='input_73' type='radio' value='Yes'  id='choice_5_73_0'    \/>\n\t\t\t\t<label for='choice_5_73_0' id='label_5_73_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_73_1'>\n\t\t\t\t<input name='input_73' type='radio' value='No'  id='choice_5_73_1'    \/>\n\t\t\t\t<label for='choice_5_73_1' id='label_5_73_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_76\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Where did you have your dating scan?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_76'>\n\t\t\t<li class='gchoice gchoice_5_76_0'>\n\t\t\t\t<input name='input_76' type='radio' value='Queensland Diagnostic Imaging'  id='choice_5_76_0'    \/>\n\t\t\t\t<label for='choice_5_76_0' id='label_5_76_0' class='gform-field-label gform-field-label--type-inline'>Queensland Diagnostic Imaging<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_76_1'>\n\t\t\t\t<input name='input_76' type='radio' value='Southern X-ray'  id='choice_5_76_1'    \/>\n\t\t\t\t<label for='choice_5_76_1' id='label_5_76_1' class='gform-field-label gform-field-label--type-inline'>Southern X-ray<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_76_2'>\n\t\t\t\t<input name='input_76' type='radio' value='Lime'  id='choice_5_76_2'    \/>\n\t\t\t\t<label for='choice_5_76_2' id='label_5_76_2' class='gform-field-label gform-field-label--type-inline'>Lime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_76_3'>\n\t\t\t\t<input name='input_76' type='radio' value='gf_other_choice'  id='choice_5_76_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_5_76_other' name='input_76_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_172\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you had a blood test with your GP?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_172'>\n\t\t\t<li class='gchoice gchoice_5_172_0'>\n\t\t\t\t<input name='input_172' type='radio' value='Yes'  id='choice_5_172_0'    \/>\n\t\t\t\t<label for='choice_5_172_0' id='label_5_172_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_172_1'>\n\t\t\t\t<input name='input_172' type='radio' value='No'  id='choice_5_172_1'    \/>\n\t\t\t\t<label for='choice_5_172_1' id='label_5_172_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_78\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >With which pathologist?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_78'>\n\t\t\t<li class='gchoice gchoice_5_78_0'>\n\t\t\t\t<input name='input_78' type='radio' value='QML'  id='choice_5_78_0'    \/>\n\t\t\t\t<label for='choice_5_78_0' id='label_5_78_0' class='gform-field-label gform-field-label--type-inline'>QML<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_78_1'>\n\t\t\t\t<input name='input_78' type='radio' value='S&amp;N'  id='choice_5_78_1'    \/>\n\t\t\t\t<label for='choice_5_78_1' id='label_5_78_1' class='gform-field-label gform-field-label--type-inline'>S&amp;N<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_78_2'>\n\t\t\t\t<input name='input_78' type='radio' value='Health scope'  id='choice_5_78_2'    \/>\n\t\t\t\t<label for='choice_5_78_2' id='label_5_78_2' class='gform-field-label gform-field-label--type-inline'>Health scope<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_78_3'>\n\t\t\t\t<input name='input_78' type='radio' value='gf_other_choice'  id='choice_5_78_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_5_78_other' name='input_78_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_79\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Has your GP arranged a Nuchal Translucency ultrasound for you?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_79'>\n\t\t\t<li class='gchoice gchoice_5_79_0'>\n\t\t\t\t<input name='input_79' type='radio' value='Yes'  id='choice_5_79_0'    \/>\n\t\t\t\t<label for='choice_5_79_0' id='label_5_79_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_79_1'>\n\t\t\t\t<input name='input_79' type='radio' value='No'  id='choice_5_79_1'    \/>\n\t\t\t\t<label for='choice_5_79_1' id='label_5_79_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_81\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Where did you have your Nuchal Translucency ultrasound?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_81'>\n\t\t\t<li class='gchoice gchoice_5_81_0'>\n\t\t\t\t<input name='input_81' type='radio' value='Queensland Diagnostic Imaging'  id='choice_5_81_0'    \/>\n\t\t\t\t<label for='choice_5_81_0' id='label_5_81_0' class='gform-field-label gform-field-label--type-inline'>Queensland Diagnostic Imaging<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_81_1'>\n\t\t\t\t<input name='input_81' type='radio' value='Southern X-ray'  id='choice_5_81_1'    \/>\n\t\t\t\t<label for='choice_5_81_1' id='label_5_81_1' class='gform-field-label gform-field-label--type-inline'>Southern X-ray<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_81_2'>\n\t\t\t\t<input name='input_81' type='radio' value='Lime'  id='choice_5_81_2'    \/>\n\t\t\t\t<label for='choice_5_81_2' id='label_5_81_2' class='gform-field-label gform-field-label--type-inline'>Lime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_81_3'>\n\t\t\t\t<input name='input_81' type='radio' value='gf_other_choice'  id='choice_5_81_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_5_81_other' name='input_81_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >If you are over 20 weeks pregnant, have you had your 18-20 week Morphology scan?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_82'>\n\t\t\t<li class='gchoice gchoice_5_82_0'>\n\t\t\t\t<input name='input_82' type='radio' value='Yes'  id='choice_5_82_0'    \/>\n\t\t\t\t<label for='choice_5_82_0' id='label_5_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_82_1'>\n\t\t\t\t<input name='input_82' type='radio' value='No'  id='choice_5_82_1'    \/>\n\t\t\t\t<label for='choice_5_82_1' id='label_5_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_83\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_83'>Date of scan<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_83' id='input_5_83' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_5_83_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_83_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_83' class='gform_hidden' value='https:\/\/metronorth.health.qld.gov.au\/redcliffe\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_5_84\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Where did you have your Morphology Scan?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_84'>\n\t\t\t<li class='gchoice gchoice_5_84_0'>\n\t\t\t\t<input name='input_84' type='radio' value='Queensland Diagnostic Imaging'  id='choice_5_84_0'    \/>\n\t\t\t\t<label for='choice_5_84_0' id='label_5_84_0' class='gform-field-label gform-field-label--type-inline'>Queensland Diagnostic Imaging<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_84_1'>\n\t\t\t\t<input name='input_84' type='radio' value='Southern X-ray'  id='choice_5_84_1'    \/>\n\t\t\t\t<label for='choice_5_84_1' id='label_5_84_1' class='gform-field-label gform-field-label--type-inline'>Southern X-ray<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_84_2'>\n\t\t\t\t<input name='input_84' type='radio' value='Lime'  id='choice_5_84_2'    \/>\n\t\t\t\t<label for='choice_5_84_2' id='label_5_84_2' class='gform-field-label gform-field-label--type-inline'>Lime<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_84_3'>\n\t\t\t\t<input name='input_84' type='radio' value='gf_other_choice'  id='choice_5_84_3'   onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_5_84_other' name='input_84_other' type='text' value='Other' aria-label='Other' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Other\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Other\"); }'   \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_88\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Are you transferring from another hospital?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_88'>\n\t\t\t<li class='gchoice gchoice_5_88_0'>\n\t\t\t\t<input name='input_88' type='radio' value='Yes'  id='choice_5_88_0'    \/>\n\t\t\t\t<label for='choice_5_88_0' id='label_5_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_88_1'>\n\t\t\t\t<input name='input_88' type='radio' value='No'  id='choice_5_88_1'    \/>\n\t\t\t\t<label for='choice_5_88_1' id='label_5_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_89\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_89'>Which hospital?<\/label><div class='gfield_description' id='gfield_description_5_89'>The name of the hospital you are transferring from<\/div><div class='ginput_container ginput_container_text'><input name='input_89' id='input_5_89' type='text' value='' class='medium'  aria-describedby=\"gfield_description_5_89\"    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_5_90\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Do you have your Pregnancy Health Record from that hospital?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_90'>\n\t\t\t<li class='gchoice gchoice_5_90_0'>\n\t\t\t\t<input name='input_90' type='radio' value='Yes'  id='choice_5_90_0'    \/>\n\t\t\t\t<label for='choice_5_90_0' id='label_5_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_90_1'>\n\t\t\t\t<input name='input_90' type='radio' value='No'  id='choice_5_90_1'    \/>\n\t\t\t\t<label for='choice_5_90_1' id='label_5_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_90_2'>\n\t\t\t\t<input name='input_90' type='radio' value='Unsure'  id='choice_5_90_2'    \/>\n\t\t\t\t<label for='choice_5_90_2' id='label_5_90_2' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_168\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class=\"alert alert-success\" role=\"alert\">\nPlease ensure you bring your Pregnancy Health Record to your appointment\n<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_91' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_5_91' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> <a type='button' href=\"javascript:void(0);\" id='gform_save_5_4_link' onclick='gform.submission.handleButtonClick(this);' data-submission-type='save-continue' class='gform_save_link gform-theme-button gform-theme-button--secondary'  > Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-91' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_5_92\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Your medical history<\/h3><\/li><li id=\"field_5_169\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Have you ever had an MRO (multi-resistant organism) infection (eg MRSA)?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_169'>\n\t\t\t<li class='gchoice gchoice_5_169_0'>\n\t\t\t\t<input name='input_169' type='radio' value='Yes'  id='choice_5_169_0'    \/>\n\t\t\t\t<label for='choice_5_169_0' id='label_5_169_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_169_1'>\n\t\t\t\t<input name='input_169' type='radio' value='No'  id='choice_5_169_1'    \/>\n\t\t\t\t<label for='choice_5_169_1' id='label_5_169_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_95\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_95'>Details<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_5_95' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_5_155\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Antenatal care preference<\/h3>\n<p>All options for maternity care are delivered by caring and dedicated health professional in partnership with you and your support people.  Your GP or Midwife will discuss these options with you.<\/p>\n<p>Choosing the best option for you will depend on your own personal preferences and sometimes, your medical history.<\/p><\/li><li id=\"field_5_157\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Antenatal Clinic Midwife Lead Care<\/label><div class='gfield_description' id='gfield_description_5_157'><a href=\"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/maternity-services\/choosing-option-maternity-care#a2001be1fe0c7d3a4\">More information<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_157'>\n\t\t\t<li class='gchoice gchoice_5_157_0'>\n\t\t\t\t<input name='input_157' type='radio' value='Yes'  id='choice_5_157_0'    \/>\n\t\t\t\t<label for='choice_5_157_0' id='label_5_157_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_157_1'>\n\t\t\t\t<input name='input_157' type='radio' value='No'  id='choice_5_157_1'    \/>\n\t\t\t\t<label for='choice_5_157_1' id='label_5_157_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_158\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Amity Midwifery Group Practice<\/label><div class='gfield_description' id='gfield_description_5_158'><a href=\"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/maternity-services\/choosing-option-maternity-care#a978af9e97feecbde\">More information<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_158'>\n\t\t\t<li class='gchoice gchoice_5_158_0'>\n\t\t\t\t<input name='input_158' type='radio' value='Yes'  id='choice_5_158_0'    \/>\n\t\t\t\t<label for='choice_5_158_0' id='label_5_158_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_158_1'>\n\t\t\t\t<input name='input_158' type='radio' value='No'  id='choice_5_158_1'    \/>\n\t\t\t\t<label for='choice_5_158_1' id='label_5_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_159\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Private Practice Midwife<\/label><div class='gfield_description' id='gfield_description_5_159'><a href=\"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/maternity-services\/choosing-option-maternity-care#6a3c37554a9bc2ad9\">More information<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_159'>\n\t\t\t<li class='gchoice gchoice_5_159_0'>\n\t\t\t\t<input name='input_159' type='radio' value='Yes'  id='choice_5_159_0'    \/>\n\t\t\t\t<label for='choice_5_159_0' id='label_5_159_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_159_1'>\n\t\t\t\t<input name='input_159' type='radio' value='No'  id='choice_5_159_1'    \/>\n\t\t\t\t<label for='choice_5_159_1' id='label_5_159_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_160\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Aboriginal and Torres Strait Islander Maternity Service - Ngarrama<\/label><div class='gfield_description' id='gfield_description_5_160'><a href=\"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/maternity-services\/choosing-option-maternity-care#0473032c5a9f69923\">More information<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_160'>\n\t\t\t<li class='gchoice gchoice_5_160_0'>\n\t\t\t\t<input name='input_160' type='radio' value='Yes'  id='choice_5_160_0'    \/>\n\t\t\t\t<label for='choice_5_160_0' id='label_5_160_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_160_1'>\n\t\t\t\t<input name='input_160' type='radio' value='No'  id='choice_5_160_1'    \/>\n\t\t\t\t<label for='choice_5_160_1' id='label_5_160_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_161\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Young Parents Program<\/label><div class='gfield_description' id='gfield_description_5_161'><a href=\"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/maternity-services\/choosing-option-maternity-care#986d71513bce0eaf3\">More information<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_161'>\n\t\t\t<li class='gchoice gchoice_5_161_0'>\n\t\t\t\t<input name='input_161' type='radio' value='Yes'  id='choice_5_161_0'    \/>\n\t\t\t\t<label for='choice_5_161_0' id='label_5_161_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_161_1'>\n\t\t\t\t<input name='input_161' type='radio' value='No'  id='choice_5_161_1'    \/>\n\t\t\t\t<label for='choice_5_161_1' id='label_5_161_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_162\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Obstetrician Led Care with Doctors<\/label><div class='gfield_description' id='gfield_description_5_162'><a href=\"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/maternity-services\/choosing-option-maternity-care#ab20e413a91db95e4\">More information<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_162'>\n\t\t\t<li class='gchoice gchoice_5_162_0'>\n\t\t\t\t<input name='input_162' type='radio' value='Yes'  id='choice_5_162_0'    \/>\n\t\t\t\t<label for='choice_5_162_0' id='label_5_162_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_162_1'>\n\t\t\t\t<input name='input_162' type='radio' value='No'  id='choice_5_162_1'    \/>\n\t\t\t\t<label for='choice_5_162_1' id='label_5_162_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_163\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >GP Shared Care<\/label><div class='gfield_description' id='gfield_description_5_163'><a href=\"https:\/\/metronorth.health.qld.gov.au\/redcliffe\/healthcare-services\/maternity-services\/choosing-option-maternity-care#73853248678309428\">More information<\/a><\/div><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_5_163'>\n\t\t\t<li class='gchoice gchoice_5_163_0'>\n\t\t\t\t<input name='input_163' type='radio' value='Yes'  id='choice_5_163_0'    \/>\n\t\t\t\t<label for='choice_5_163_0' id='label_5_163_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_5_163_1'>\n\t\t\t\t<input name='input_163' type='radio' value='No'  id='choice_5_163_1'    \/>\n\t\t\t\t<label for='choice_5_163_1' id='label_5_163_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_164\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Please be aware, your medical and obstetric history will determine whether you need to see a doctor on the same day, immediately following your booking in appointment.<\/p>\n<p>Appointments within school hours are extremely popular and can not always be accommodated.<\/p>\n<p>Your partner or a support person, or young children are welcome to attend with you. However, please be aware your personal medical and social and history will be discussed and the appointment can be up to 1 hour.<\/p>\n<p>An ultrasound scan does not occur at this visit.<\/p>\n<p>It is important to keep us informed of your current address and telephone numbers. We may need to contact you regarding results or to change an existing appointment.<\/p><\/li><li id=\"field_5_165\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Information disclaimer and consent<\/h3>\n<p>Personal information you provide in this form will be used by Queensland Health to assist in chart preparation for your pregnancy booking in visit and to assess your individual pregnancy health care needs.<\/p>\n<p>While Queensland Health endeavours to ensure that the online transmission of the form, containing your information, over the internet is secure, the inherent nature of the internet means that there is a potential risk that your information may be viewed or intercepted by third parties.<\/p>\n<p>Accordingly, submission through the online form shall be at your own risk and Queensland Health accepts no responsibility or liability for any unauthorised access to your information contained in the form when it is submitted online over the internet.<\/p>\n<p>It is inadvisable to complete this form on a public or shared computer. If a public or shared computer is used then this shall be at your own risk, and you must take all reasonable steps to ensure your confidential information does not remain on the computer or in any way accessible by a third party.<\/p>\n<p>Individuals who submit the form online should receive an acknowledgement from Queensland Health that the Form has been sent, on the screen, following submission. Queensland Health accepts no responsibility or liability if this acknowledgement does not appear or we do not receive your online submission.<\/p><\/li><li id=\"field_5_166\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><b>I hereby accept and agree to abide by, the above terms and conditions for submitting this form<font color=\"red\">*<\/font><\/b><\/p><\/li><li id=\"field_5_167\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_5_167'><li class='gchoice gchoice_5_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='I accept and agree'  id='choice_5_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_167_1' id='label_5_167_1' class='gform-field-label gform-field-label--type-inline'>I accept and agree<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_5_173\" class=\"gfield gfield--type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_173'>CAPTCHA<\/label><div id='input_5_173' class='ginput_container ginput_recaptcha' data-sitekey='6LcwcSYUAAAAAFZ0zEoKZIk2yQMA-9rTK4mA5xqZ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input 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