Birth / Placenta Services Intake Form

Contact Information

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First Name

Last Name

SMS Number

Address

Address 2

City

Zip Code

Company

Title

Office Phone

Website

Emergency Contact

Emergency Contact Phone

Emergency Contact Email

Pregnancy Details

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EDD or Baby's Birth Date

Which hospital or birthing center are you planning to give birth at?

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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Where are you getting prenatal care? 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.

What are your top priorities for your birth? (select all that apply)

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)

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Bellevue Hospital
BronxCare Hospital Center
Brookdale Hospital and Medical Center
Brooklyn Birthing Center
Brooklyn Hospital Center
Elmhurst Hospital
Flushing Hospital
Harlem Hospital
Jacobi Medical Center
Jamaica Hospital Medical Center
Kings County Hospital Center
Lenox Hill Hospital
Lincoln Medical Center
Long Island Jewish Forest Hills
Long Island Jewish Medical Center (Katz)
Maimonides Medical Center
Metropolitan Hospital Center
Montefiore Medical Center - Wakefield
Montefiore Medical Center - Weiler / Einstein)
Mount Sinai Hospital (East)
Mount Sinai West
New York Downtown Hospital Center
NY Presbyterian - Allen Hospital
NY Presbyterian - Brooklyn Methodist Hospital
NY Presbyterian - Columbia (Sloan / Morgan Stanley)
NY Presbyterian - Koch Center (Alexander Cohen)
NY Presbyterian - Lower Manhattan Hospital
NY Presbyterian - Queens
NY Presbyterian - Weill Cornell
North Central Bronx Hospital
NYU Langone - Brooklyn / Lutheran Medical Center
NYU Langone - Tisch
NYU Langone - Other
Queens Hospital Center
Richmond University Medical Center
South Brooklyn Health (previously Coney Island Hospital(
St Barnabas Hospital
St John's Episcopal Hospital
Staten Island University Hospital
SUNY Downstate Medical Center / University Hospital of Brooklyn
Woodhull Hospital
Wyckoff Heights Medical Center