Childbirth Education Sign-Up sheet

Childbirth Education

Sign up sheet
Congratulations on your pregnancy! Thank you for taking the time to fill out this form so I can get to know you better and have an idea of how I can best support you during your pregnancy and birth!
Your Name*

First NameLast Name
Your Birthday

MonthDayYear
Date
Phone*

Area CodePhone Number
Where are you from?*
E-mail*
Your Partner's Name (or who will attend classes with you)

First NameLast Name
What is your relationship to the person attending class with you?
Doctor/ Midwife's / Practice name*

First NameLast Name
Hospital or Homebirth?*
About your baby
Estimated Due Date*

MonthDayYear
Baby's Gender

BoyGirlUnknownBoy & Girl (twins)Boy twinsGirl twinsMultiples
Planned Method of Feeding

BreastfeedingFormula FeedingBothNot sure but would like more information
Preperation for Birth
Have you given birth before?*

NoYes,Vaginally onlyYes, Cesarean onlyYes,Vaginally and Cesarean
Planned Method of Delivery*

Vaginal - no medicationsVaginal - medicatedVBACC-sectionUnsure (I would be more than happy to discuss options with you!)
Have you hired a doula?

Yes! I have a doulaNo, I don’t have a doulaWhat is a doula?
If you don’t have a doula would you be interested in hiring one?

I am unsure and need moreI am unsure and need more informationNo, I am not interested
Who do you plan to have assist you with your labor?*

PartnerDoulaMother/ Mother-in-LawSisterFriendOther
Do you have a birth vision planned?

Yes, It is a final copyYes, but it is a draft and would like some helpNo, I would like some help writing one.No, I have no interest in one.
In-person class options:*

Private ($150)Group classes ($100)
Disclaimer: $100 (group classes) or $150 (one-on-one classes) payment is due by the first day of class. Services will NOT be provided to those who fail to pay. Once you’ve submitted the sign-up sheet we will send you a link to the invoice and you can pay online or with cash.*

I agree
Initials*
Are interested in any other services SHILOH BIRTH offers?

Birth DoulaPlacenta EncapsulationPostpartum support
Any questions or concerns?
Should be Empty: