Name
*
First Name
Last Name
Your Date of Birth
MM
DD
YYYY
Email
*
Phone
(###)
###
####
Physical Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Partner's Name
First Name
Last Name
Partner's Email
Partner's Phone
(###)
###
####
What hospital, birth center, or location to you intend to give birth?
Briefly detail any past pregnancies and births, including miscarriages
Briefly describe your health history, including any surgeries or allergies
Due Date
MM
DD
YYYY
Type of Pregnancy
Singleton
Twin
Triplet
What part of labor and birth are you most excited for?
What is your biggest hope or preference for your birth?
How do you hope I can help you in your birth?
Have you had any complications in this pregnancy?
Has your provider given you any restrictions for pregnancy of birth? (ex. bed rest, induction, c-section)
Have you experienced any traumatic events in your life that you believe could make birth more challenging? (ex. abuse, medical complications or injuries, loss)
Is there anything during your pregnancy, birth, or recovery that you would especially like to avoid?
How do you plan to feed your baby?
Is there anything else you would like me to know?
Contract & Deposit
*
"I agree to be supported by Ellenore Kewin during my pregnancy and labor, which includes a prenatal visit, ongoing support during the labor and birth, and a postpartum visit. I agree to pay a $200 deposit after the initial consultation and the remaining $500 after the birth."
