Birth Doula Contract & Intake Form

Birth Doula Contract & Intake Form
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Due Date

MonthDayYear
Date
Partner Involved

YesNoPrefer not to answer
Partner or Emergency Contact
Preferred Birth Location
Special Concerns
Health Conditions & Allergies
OBGYN/Midwife
Are you working with any other health care provider?

YesNo
If Yes, please specify

Agreement & Responsibilities Acknowledgment
Acknowledgment of Responsibilities*

I understand the importance of openly communicating my concerns, needs, and preferences during pregnancy, labor, and postpartum.I agree to notify the doula as soon as I think I’m going into labor.I acknowledge the hospital regulations and will ensure the hospital consents to the doula’s presence.I understand the service limitations of the doula.

Liability Release and Photo/Video Release
Liability Release Agreement*

I acknowledge that I have read and understood the liability release terms.
Photo and Video Release Agreement*

I grant permission for photographs and video recordings to be taken and used as described.I Do Not grant permission

Confidentiality, Cancellation, Backup Doula, and Force Majeure Terms
Terms and Conditions Acknowledgment*

I acknowledge and agree to the confidentiality terms as outlined.I understand and accept the cancellation policyI agree to the possibility of a backup doula being arranged if necessary.I accept the force majeure clause regarding unforeseen circumstances.

Dispute Resolution, Severability, Indemnification, Entire Agreement, and Signature Fields
Contract Clauses Acknowledgment*

I acknowledge the dispute resolution process as outlinedI understand the severability clauseI agree to the indemnification termsI accept the entire agreement clause
Client Signature

Clear
Date

MonthDayYear
Date
Doula Signature

Clear
Date

MonthDayYear
Date
Should be Empty: