New Client Birth Questionnaire 

Estimated Due Date: *
Estimated Due Date:
Tell me about you
Name *
Name
Phone *
Phone
Alternate Phone
Alternate Phone
Partner's Name *
Partner's Name
Partner's Phone
Partner's Phone
Address *
Address
Tell me about your birth (upcoming and/or past births)
Location address:
Location address:
Phone number of practice:
Phone number of practice:
People in attendance: *
List any people that will be attending the birth of your baby. Check any that apply.
Current pregnancy: *
How is it progressing? Check any that apply.
Past labors *
If this is not your first labor, can you please describe how you past labor/deliveries have gone? Check any that apply.
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:
Let's talk about pictures during your labor & delivery
What I would like photographed: *
Check any that apply.
I want most of my pictures to be of: *
Social Media
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.
Would you like me to post a birth announcement and/or birth story blog post about your birth experience? *
A birth announcement would be posted on Facebook within 48 hours of your birth experience.
A blog post would likely be published within a few weeks.
Are you comfortable with me posting non-identifying social media updates about your labor & delivery experience? *
Do you want to be tagged in images on social media? *