BREATH OF LIFE MIDWIFERY LLC
Crystal Fink CPM, LM - SAVANAH SONGER CPM, LM
117 Sheraton Dr. Salem, VA 24153 Phone: (540) 676-7288 Fax: (540) 301-1768
Email: firstname.lastname@example.org www.breathoflifemidwifery.webs.com
Complete this medical release for any providers you have used during this pregnancy or previous pregnancies. Complete and submit a new form for each provider.
Medical Release Form
Sometimes people have had life experiences that left them traumatized and that they had to recover from. Sometimes that involves assault or abuse, or even being in a car accident. There may be things that other people do or say that lead you to being instantly scared or startled or remind you of that original traumatizing experience. I just want you to know that I can help you best when I can help myself and others to avoid those behaviors, and what to do if they happen.
You do not have to disclose why, but if desire we are happy to discuss your experiences and support you.
Please complete the following forms prior to your first visit: