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Birth Doula Contract Form    Copy and Download
Estimated Due Date or Baby's Birthdate *_________________________________
Name * First_______________________________________________________
Last_____________________________________________________________
Address *_________________________________________________________
Line 1 ____________________________________________________________
Line 2____________________________________________________________
City _____________________________________________________________
State_______ Zip Code __________Country _____________________________
Home Phone Number _______________________________________________
Cell Phone Number _________________________________________________
Email ____________________________________________________________
​HOW WOULD YOU PREFER TO COMMUNICATE?
Occupation _______________________________________________________
Time Off?     _______________________________________________________
If yes, how much time? _______________________________________________
Do you have a Partner?_______________________________________________
Partner's Name  ____________________________________________________
Partner's Cell Phone _________________________________________________
Will your partner be taking time off work? ________________________________
If yes, how much time will your partner take off? ___________________________
Gender(s) of baby  if known: *_________________________________________
Midwife or OB/GYN Name * First_______________________________________
Last_____________________________________________________________
Midwife or OB/GYN Phone Number *____________________________________
Planned Birth Location? *_____________________________________________
Back up hospital if planning a home birth *________________________________
Pediatrician's name  First/Last _________________________________________
Pediatrician's Phone Number *_________________________________________
Have you taken a childbirth class? *_____________________________________
If yes, what childbirth course and when. *_________________________________
Are you planning to breast or bottle-feed? *_______________________________
Do you have other children? *__________________________________________
​Will they be attending the birth?________________________________________
If yes, what are their names and ages? *__________________________________
________________________________________________________________
Please briefly describe the births and postpartum experiences of your other children if applicable....
​_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Is there anything in your medical or emotional history you would like to share with me?
_________________________________________________________________
​_________________________________________________________________
​_________________________________________________________________
Have you experienced any complications with your pregnancy? _________________________________________________________________
​_________________________________________________________________
Do you have religious preferences? _________________________________________________________________
Do you have any fears about your upcoming birth? _________________________________________________________________
​_________________________________________________________________
Please mark any of the following items that you would like included in the contract:
Breast Feeding Information (Included with birth pkg)
Cloth Diapering________
Babywearing Information_______
Nutrition/Exercise for Pregnancy__________                                                             Photography before, during and /or after the birth. __________                         Personal Childbirth Birth Instruction__________                                                             Paintings or Jewelry Making (Create Heirlooms /early stages of labor________                                                                                                                                   Music to Birth by_____________                                                                                                Painted Belly Casting____________                                                                                            Baby Swaddling Instruction __________                                                                             Your Written Birth Story (Included in basic package)___________

Video Possible_____________                                                                                                 Placenta Encapsulation____________

​TOTAL PRICE _________________________
I agree to pay 50% of our agreed upon price upon the signing of this contract and the final portion to be paid within 7 days of delivery.
CLIANT SIGNATURE___________________________Date________________

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