Estimated Due Date
*
MM
DD
YYYY
Name
*
Tell me about you
First Name
Last Name
Phone
*
(###)
###
####
Email Address
*
Partner's Name
*
First Name
Last Name
Partner's Phone
(###)
###
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Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Location:
*
Hospital
Birth Center
Home
Other
Name of care provider:
*
Location address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone number of practice:
(###)
###
####
People in attendance:
*
Check all those who will be attending your birth.
Others - please explain:
Current pregnancy:
*
How is it progressing? Check any that apply.
Past labors:
*
If this is not your first labor, please describe how your past labor and delivery went. Check any that apply.
Other - please explain:
Do you know the gender of your baby?
*
Transfer
*
If for any reason you are to be transferred from home to hospital or from one hospital to another for any reason would you want me to:
What would you like photographed?
*
Check any that apply.
Other - please explain:
I want most of my pictures to be of:
*
Social media - Are you comfortable with me posting non-identifying social media updates about your labor & delivery experience?
*
As you probably know, social media is my largest tool for sharing my work. I would love the opportunity to share your (non-revealing) birth images in my portfolio and with my followers. But, ultimately, the decision is up to you.
Do you want to be tagged in images on social media?
*
Any additional comments or information?
