Doula Client Intake Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How do you plan to pay? *

Private Pay (includes using HSA/FSA payments)

Medicaid

Do you understand that a non-refundable retainer of $350 is due at the time of booking my services? *

*Payment plans are accepted*

Yes

Support person's relationship to you

Spouse

Partner

Parent

Sibling

Friend

Other

Support person's phone number *

(###)

###

####

Estimated due date *

MM

DD

YYYY

Type of provider *

OBGYN

Midwife

Other

Baby's sex *

Male

Female

Suprise

What number baby is this? *

*If other; please explain*

Baby #1

Baby #2

Baby #3

Baby #4

Other

Do you have a history of miscarriage or stillbirth? *

Yes

No

Have you received fertility treatments? *

Yes

No

Have you had a c-section before?

Yes

No

Do you have any prenatal complications this pregnancy?

Yes

No

If yes: please check all that apply

Group B Strep

Preeclampsia

Gestational Diabetes

IUGR

Mult. Pregnancy (twins, triples, etc)

Preterm Labor

STD/STI (please explain)

Other

Do you have any other medical conditions that I should be aware of (including allergies to essential oils and honey) *

Yes

No

Are you okay with students being in the room?

Yes

No