New Client Form First & Last Name(required) Email(required) Phone Number Home Address Birthday Estimated Due Date Pregnancy Number Have you delivered early with previous births? If so, how early? Name of Care Provider Care Provider Type Midwife CNM OB/GYN Have you used this care provider before? Where will you be birthing? Address of birthing location How did you hear about me? What is your desired style of birth? Natural Medicated Planned Cesarean Planned Induction Undecided What style of birth were your previous birth(s)? Are you attempting a VBAC? (vaginal birth after cesarean) Have you had any complications with this pregnancy? If so, please explain Do you have any allergies? Medication, food, lotions, etc. If so please explain In your own words, what would you like your birth experience to be like? What would you like to avoid in your birth? How would you like me, as your doula, to help you achieve your desired birth? Has a doula attended your previous birth(s)? How much does your birth partner intend to be involved? Who else will attend your birth? Which of the following do you respond most favorably? Please type each one that applies: Smell, Touch, Positive Words, Music What are some things you find helpful when you are stressed or uncomfortable? Which of the following are you interested in using for pain management? Please list all that apply: Birth Tub, Shower, Massage, Breathing, TENS (Transcutaneous Electrical Nerve Stimulation), Essential Oils/Lotions, Birth Ball Have you attended a birthing class? Do you already have a birth plan in place? Submit Δ ________________________________________________ AdvertisementShare this:TwitterFacebookLike this:Like Loading...
Yours Truly 