ORA DOULA SERVICES
Independent Appointment Intake Form
Doctor/ Midwife/ Practice:
Street Address Line 2
State / Province
Postal / Zip Code
About Your Baby
Estimated Due Date or Baby's Birth Date
Baby's Name (if you'd like to share)
If you're in your 3rd trimester, what is your baby's current position in the womb?
Head down/ Anterior
Head down/ Posterior
I'm not sure
If you selected "Other" above, please specify:
About Your Health
Please state your general health.
Do you have any chronic conditions I should be aware of?
Have you given birth before? (select all that apply)
Yes, by C-section
Please explain any complications you have had with this pregnancy/birth/post partum period, any restrictions your medical provider has given you, and any medications you are currently taking.
About This Appointment
I would like an appointment for: (select all that apply)
Peer Mental Health Screening
Birth Trauma Processing
I'm not sure yet
What are your hopes or fears about your pregnancy, birth, or post partum period?
What do you hope to gain from this appointment?
What questions do you have for me?
When would you like to schedule this appointment? (select all that apply)
As soon as possible
I have a date or range of dates in mind
I prefer morning
I prefer afternoon
I prefer evening
I prefer weekend
I prefer weekday
If you have a date or range of dates in mind, please specify:
I will pay by check.
I will pay with cash.
I will pay via PayPal.
I will pay with HSA/FSA.
I would like to pursue insurance reimbursement.
I qualify for reduced/waived fee.
I would like to discuss a payment plan.
Should be Empty:
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