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Assertion to Decline Tests Required within 28 Weeks Midwife Mobile App

Midwives can use the Assertion to Decline Tests Required within 28 Weeks Midwife mobile app with a smartphone or tablet to have their patients sign and acknowledge their refusal to required 28 weeks pregnancy tests. The app includes test name and details, risk to mother and risks to unborn child.

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Customize to add, remove, or edit any of the fields below.

Name of Midwife:
ADHS License #:
Midwife’s Phone #:
Midwife’s E-mail:
LM Client File #:
Client’s Name:
Date of Birth:
Client’s Ph.
Client’s E-mail:
Client’s Street Address:
City:
State:
Zip:
The Midwife and the Client affirm with their signatures below that the client has declined the on...
Midwife Signature:
Date:
Test
Date Declined
Client Signature
Midwife Initials
...and More!

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