Client Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Client Due Date
Client Doctor
Hospital/Birth Center
Phone Number
*
Please enter a valid phone number.
Emergency Contact Person
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
How did you hear about us?
Medical Condition
Do you have any medical conditions or concerns?
*
Are you currently taking any medications? If yes, please list them below.
*
Do you have any allergies? If yes, please list them below.
*
Do you have any of the following?
Yes
Details of Condition
High Blood Pressure (Hypertension)
Arrhythmias or Irregular Heart Beats
Swelling (Edema)
Lung Disease (Pulmonary)
Congestive Heart Failure (CHF)
History of Heart Attack (MI)
Abnormal EKG
Kidney Disease
Anemia
Asthma
Bleeding/Clotting Disorder
Diabetes
History of Stroke
History of Anxiety
Night Sweats
Sudden Weight Loss
Skin Disorder
G6PD Deficiency (Retinal Disease)
Have you been diagnosed as high risk?
*
Yes
No
Do you have any concerns you would like to discuss?
Acknowledgment
Check acknowledgment
I understand that my doula is NOT a medical provider.
I understand that I am to contact my medical provider with any medical concerns or issues.
I understand that doula services are solely for emotional, practical, social and informational support, and do NOT substitute for a licensed medical care provider.
I certify that all information in this form is accurate and true to the best of my knowledge.
I grant permission to Mahogany Maternity to take photographs or videos for the purpose of client and family use, with client phone/camera. Photographs will only be shared with Mahogany Maternity with written, express permission of client, and only for use for promotional advertisement.
*
Yes
No
Your Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Would you be willing to consider providing a testimonial upon the completion of out services?
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