Newborn Care Assessment
Congratulations on your baby! Please take some time to answer the questions below regarding your new baby and how we can support you.
Name
*
First Name
Last Name
Spouse/Partner's Name
*
First Name
Last Name
How old are you and your spouse?
*
What are your occupations? (Some careers pose certain hurdles with a new baby. If we know your occupation, we can coach and support you better with your new baby.)
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
How did you hear about us?
*
How has your pregnancy been so far? Any concerns or complications?
*
When is your baby due to arrive?
*
Is this your first child?
*
On a scale of 1-5 how prepared do you feel for the birth of you baby?
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Not at all
1
2
3
4
Very prepared
5
1 is Not at all, 5 is Very prepared
On a scale of 1-5 how prepared do you feel for the first 6 months with a newborn?
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Not at all
1
2
3
4
Very Prepared
5
1 is Not at all, 5 is Very Prepared
Tell us about any concerns you have regarding birth or life with your new baby.
*
Why are you interested in having a naturopathic pediatrician for your baby?
*
On a scale of 1-5, how important is it for your baby to be healthy from birth through childhood and beyond?
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Not Important
1
2
3
4
Very Important
5
1 is Not Important, 5 is Very Important
Why are you interested in our newborn concierge program?
*
Concierge care is not inexpensive. Are you able to make an investment in keeping your baby healthy from birth and setting them up to be a healthy child?
*
Yes
No
What else would you like us to know so we can best serve you?
*
What questions do you have for us?
*
Thank you for taking the time to fill out this form. We will contact you shortly to help determine the next best steps for your family.
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