Estimated Due Date
Estimated Due Date
Name *
Name
Phone
Phone
Your Partner's Name
Your Partner's Name
Your Partner's Phone
Your Partner's Phone
Phone Number of Practice:
Phone Number of Practice:
Who will be with you during this birth?
Are there any moments that you would be heartbroken if they are missed?
Past Pregnancies
If this is not your first labor, can you please describe how you past labor/deliveries have gone? Check any that apply
What would you like photographed?
Check all that apply.
Are you sensitive to any scents or noise? How do you prefer the lighting to be ? Are there any boundaries or preferences I should know about?
I am most interested in photos:
If for any reason you are to be transferred from home to hospital or from one hospital to another for any reason, would you want me to:
Would you like me to post a birth announcement and/or birth story blog post about your birth experience? A birth announcement or blog post would be published after YOU have announced the birth on your own FB pages.
Are you comfortable with me posting non-identifying social media updates about your labor & delivery experience?
Do you want to be tagged in images on social media?