MB Intake Mindful Birth Intake Form Please complete prior to attending Mindful Birth Class 1. Go backYour message has been sent Name(required) Warning Email(required) Warning Best Number to Reach You(required) Warning Address Warning Estimated Due Date(required) Warning Occupation Warning Birth Partner Name (Leave Blank if Single) Warning Birth Partner Occupation Warning Midwife/OB Name or Practice Name(required) Warning Planned Place of Birth Home Hospital Birth Center Warning Doula (If Applicable) Warning How did you hear about the class? Warning Is there anything that would currently prevent you from having the birth you desire? Warning Are there any considerations that I can provide to make this class more comfortable or inclusive for you or your partner? (Ex: disability awareness, pronouns, non-gendered language, etc) Warning I understand that the content of this series is in no way intended to be represented as medical advice nor as a prescription for medical procedures. I am aware that I should seek the advice of a midwife or doctor to answer my health or pregnancy related concerns. I agree that I will not hold the instructor responsible for any complications that could arise as a result of my pregnancy or birth. I understand that my childbirth educator does not guarantee a specific outcome for any student’s birth.(required) I agree I do not agree Warning Warning. SubmitSubmitting form Δ Share this: Click to email a link to a friend (Opens in new window) Email Click to print (Opens in new window) Print Click to share on Pinterest (Opens in new window) Pinterest Click to share on X (Opens in new window) X Click to share on Facebook (Opens in new window) Facebook Like Loading...
Julie Byers 