Date______________ Patient _______________________________ Date of birth____________ MR #___________
Physician or certified nurse–midwife______________________________ Last menstrual period__________________
Estimated date of delivery_______________ Best estimated gestational age_____________
❏ Patient has been counseled on the risks, benefits, chances of success, and alternatives of planned trial of labor after cesarean delivery (TOLAC) (1)
❏ Patient is informed of the facility’s ability to perform an emergency cesarean delivery and the avai...