MB Intake Mindful Birth Intake Form Please complete prior to attending Mindful Birth Class 1. Name(required) Email(required) Best Number to Reach You(required) Address Estimated Due Date(required) Occupation Birth Partner Name (Leave Blank if Single) Birth Partner Occupation Midwife/OB Name or Practice Name(required) Planned Place of Birth Home Hospital Birth Center Doula (If Applicable) How did you hear about the class? Is there anything that would currently prevent you from having the birth you desire? 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) 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 Submit Δ Share this:EmailPrintPinterestTwitterFacebookLike this:Like Loading...
Julie Byers 