Mewinzha Ondaadiziike Wiigaming Interest Form
Name
*
First Name
Last Name
What name would you like to be called by?
*
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid secondary phone number if applicable.
Format: (000) 000-0000.
Email
example@example.com
Please select which services you're interested in connecting with us about.
*
Clinic Offerings
Doula Offerings
Holistic Health Offerings
Nutrition Offerings
Other
Our health services are mostly covered by insurance, including holistic health benefits. We strongly believe that utilizing these benefits is important for promoting community health and wellness. In order to help promote and expand our services, we would like to know if you would be willing to provide your insurance information.
Yes, I have health insurance and would like to provide this information
I prefer not to share my insurance information at this time
I do not have health insurance at this time, but would like to be connected to resources that can help me review options
I do not have health insurance at this time, and do not wish for additional information.
Unsure, I'd like to discuss this more during my initial call.
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Clinical Services
Please select which services clinical offerings you're interested in connecting with us about.
Well Women’s Health Exams: Including pap smears, breast exams, and referrals for screening mammograms.
Birth Control Education, Consultation, and Prescriptions.
Pregnancy Testing
Prenatal Care
Postpartum Care
Lactation Education and Support
Other
Is there any additional information that might be helpful for our team to know?
Submit
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Doula Services
Please select which services doula offerings you're interested in connecting with us about.
Pregnancy Education and Support
Labor and Delivery Support
Postpartum Education and Support
Lactation Education and Support
Other
Is there any additional information that might be helpful for our team to know?
Submit
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Holistic Health
Please select which services holistic health offerings you're interested in connecting with us about.
Traditional Wellness Clinic
Plant Medicines
Reiki
Healing Touch
Cedar Bath
Other
Is there any additional information that might be helpful for our team to know?
Submit
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Nutrition
Please select which services nutritional offerings you're interested in connecting with us about.
Individualized nutrition counseling
Diabetes education
Cooking workshops
Meal planning
Grocery store tours
Meal preparation for prenatal and postpartum families
Other
Is there any additional information that might be helpful for our team to know?
Submit
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