Registration Form | Birth Matters Doula Care

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New Client Intake Form

Questionnaire & Consent Form
Please fill out the following form prior to your first appointment or first class

Birthing Person Name

Age *

Profession

Estimated Due Date

Name of Care Provider (Dr/Miwife)

Name & Date of Class you are attending OR date of appointment

Partner/Support Person's Name

Age *

Profession

Phone

Preferred / Personal Email

Planned Place of Birth

Is this you or your partner's first birth experience?

My first time

Their first time

Previous birth experience

Share your previous birth experience (if applicable)

What areas of pregnancy, childbirth, recovery or postpartum do you especially hope to learn about in class?

What are your plans regarding the use of medication for labor and birth? (for prenatal class students)

What are your plans for feeding baby?

Hoping to Breastfeed

Planning on using Formula

Both

Not Sure

Any special information that you feel your practitioner/educator should be aware of that would help them get you the right information/treatment during your sessions.

We understand that appointments in the clinic space masks are currently MANDATORY & inside the classroom/studio it is by our own preference & we also agree to monitor for COVID symptoms and not attend if unwell(this is a requirement for all HealthCare settings per IH)

CONSENT TO TREATMENT DURING COVID19

We understand that while the Doula/Educator is following all of the current health and safety guidelines outlined by the Provincial Health Officer & BCCDC and that they are taking all reasonable precautions to clean and disinfect the Office & Studio and all the surfaces there are no guarantees that I may not come into contact with COVID-19.

PRIVACY AND INFORMATION SHARING

I authorize the Doula/Educator to collect this personal health & contact information as documented above for the purposes of educational enhancement & contact tracing. I also understand that my personal and medical information shared is confidential and will only be disclosed to third parties with my permission.

Your Signature

Use your mouse or finger to draw your signature

Thanks for submitting!

Birth Matters Doula Care & Prenatal Classes

BIRTH MATTERS | KAMLOOPS, BC

EMAIL: admin@yourbirthmatters.ca

503- 1315 Summit Drive

(Tudor Village, within Modern Nest)

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New Client Intake Form

Questionnaire & Consent Form Please fill out the following form prior to your first appointment or first class

Questionnaire & Consent Form
Please fill out the following form prior to your first appointment or first class