Ora Doula Services Intake Form

ORA DOULA SERVICES

New Client Intake Form
Your Name*

First NameLast Name
Your date of birth*

MonthDayYear
Date
Your Partner's Name

First NameLast Name
Doctor/ Midwife's / Practice name*

NamePractice
Delivery Location*
Home Address (for prenatal and postpartum appointments)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Yes please!
Phone*

Area CodePhone Number
Basic Birth Package: 2 prenatal appointments, labor & birth support, 1 brief postpartum appointmentNourishing Birth Package: 2 prenatal appointments, labor & birth support, nourishing postpartum appointment with meal prepared by Cocina Cura, herbal bath if birth was vaginal, 2-3 hours of postpartum doula services
About your baby
Estimated Due Date*

MonthDayYear
BoyGirlUnknown
Baby's name (if known)
BreastfeedingFormula FeedingBothNot sure but would like more information
About your health
Please state your general health
Do you have any allergies I should be aware of?
Explain any complications you have had with this pregnancy, any restrictions your caregiver has given you, and any medications you are currently taking.*
Preperation for Birth
NoYes, Vaginally onlyYes, Cesarean onlyYes, Vaginally and Cesarean
Have you taken or are you planning on taking any childbirth education classes? If so, what are they and where are you attending them?
Please list any other classes you have taken or plan on attending.
PartnerDoulaMother/ Mother-in-LawSisterFriendOther
Who do you want present for the delivery?*
How do you feel about interventions in labor/delivery?
Comfort MeasuresIV MedicationEpiduralOther
DistractionsBreathing PatternsMassageBirth BallWalking, Dancing, SwayingWater (tub/shower)Visualization/ImageryBirth AffirmationsAromatherapyMusicRebozoI don't know yet!
What is your vision for this birth? *
What are your expectations of me as your doula?*
Any other questions or concerns?
I will pay by check.I will pay with cash.I will pay via PayPal.I will pay with HSA/FSA.I am interested in a payment plan.I would like to contribute to the scholarship fund for low income clients.
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ORA DOULA SERVICES