Birth / Placenta Services Intake Form

Contact Information

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First Name

Last Name

SMS Number

Address

Address 2

City

Zip Code

Emergency Contact

Emergency Contact Phone

Pregnancy Details

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EDD or Baby's Birth Date

Hospital / Place of Birth

Explain any complications that you have had with this pregnancy, any restrictions your provider has given you, and any medications (prescription or OTC) / natural supplements / vitamins you are currently taking.

Please state your general health. Do you have any conditions (physical or psychological) or recent illnesses, surgeries, accidents, or trauma that we should be aware of?

Do you have any cultural customs you would like honored at your birth? Please explain so we can help ensure that happens.(optional)

Have you given birth before?

How many pregnancies have you had? (Please include miscarriages, abortions, and stillbirths)

Are you having twins or multiples?

Do you currently see a therapist or counselor?

Do you have any food/scent/latex allergies or aversions?

Birth Doula Services

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Care Provider Name and Address

Who will be present at your birth? Please include names, pronouns, contact information, and relationship to you.

During labor, birth and postpartum, emotions associated with prior trauma can come to the surface. As your support, it may be helpful for us to be aware of this history and what your triggers are or may be.

Timing

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Referral Source

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Notes

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Anything you'd like us to know?

SUBMIT

Apply for Founder-Level Birth Support

Limited, high-touch care with Miranda Padilla (1 client/month)