Doula Contract Client Form

Doula Services Contract/Agreement

Angie Hotz (515) 661-4738
As a birth doula, I provide educational, emotional, and physical support to a woman/birthing person during their labor and delivery. I can also facilitate communication with the staff to ensure that you have the information you need to make informed decisions regarding your baby’s birth. I can provide reassurance and perspective to you and your partner, make suggestions for labor progress, and help with relaxation, massage, positioning and other techniques for your comfort. I am independent and self-employed, and as such, am working for YOU, not your caregiver or place of birth.
Pregnant person's Name *

First Name Last Name
Partner's Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Estimated Due Date *
Intended Place of Birth *
Preferred method of communication (text, email, messenger, etc) *
Please read the below attached doula contract PDF before agreeing to the terms.

The service agreement lists all the services provided by Angie, your responsibilities as a client, as well as limitations including in the event of an unexpected cesarean.

Please feel free to download the contact.
I acknowledge and agree to the following (copied directly from above contract) *

I have read all of the above PDF service agreement I agree to pay in full the amount of $1300 I understand that the $300.00 deposit paid at the signing of the contract is non-refundable under any circumstance. (the deposit is included in the $1300 total) I agree to pay the remaining balance in full by 38 weeks gestation(Unless other arrangements are made) in order for Angie Hotz to be on call for my labor and childbirth. I understand that Angie is not working for the hospital or midwife, but is hiredby me to meet my needs. I understand that Angie is not here to make decisions or to enforce ourdecisions, but to help me to know my options and encourage me to enforce my owndecisions. I understand that Angie Hotz will provide emotional and physical support to bothmy labor partner (spouse, mother, etc.) and to me. I understand that if it appears that labor is going forward too quickly to make it to theLabor and Delivery ward, I am giving Angie Hotz permission to call 911 and request ambulance assistance to my home. If I am birthing at home, I give Angie permission to call my attending midwife immediately. I understand that it is my responsibility to call Angie when I believe that I am in labor in order for her to attend my birth. She will provide triage over the phone so we can decide when it is best for her to arrive at my home or the hospital. I understand that Angie has up to 2 hours to arrive at my home or the hospital from the time she is called in due to circumstances beyond her control such as unfavorable weather. **I understand that If I do not call Angie and request that she come to the birth place, a refund will not be given if she does not attend the birth due to my not calling her.** I understand that if Angie cannot attend my birth, due to circumstances outside of her control, her backup doula will attend in her place and I will not be entitled to a refund unless the backup doula is unable to come to the birth, either. If this occurs, I will be entitled to up to 50% of my total paid fee. (this does not include when I choose not to call)
Services Angie Hotz does not provide for birth doula packages:

● Any type of medical care, diagnosis of illness, prescription of any sort of substance, cervix checks, fetal monitoring, administration of medical, any type of medical care for your baby are not provided and out of scope of a birth doula.

● Any guarantee of an unmediated or vaginal childbirth. Doulas provide planning and education for families to make informed choices while understanding that there is risk involved in any facet of the birth process.
Please note any specific individual arrangements, agreements, or other - not already covered in this contract:
Please indicate Deposit/retainer payment options, other than PayPal (after choosing one of these options, skip down to the signature, date, and submit)

Venmo to @Angie-Hotz for $300 Mail a check for $300
If mailing a check, mail check to:

Angie Hotz

1410 Gregory Way

Bremerton, WA 98337
PayPal Online Payment Option (notice the additional fee for using PayPal)
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Deposit/retainer for doula services (included in total) $ 310.00
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Doula Services Contract/Agreement