Name
*
First Name
Last Name
Pronouns
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Partner Name
*
First Name
Last Name
Pronouns
Phone
*
(###)
###
####
Estimated Due Date
*
MM
DD
YYYY
Other Children and Ages (if applicable)
Birthing Location
Care Provider Name
Previous Birthing History
As applicable—VBAC, length of past labors, episiotomy, loss, etc.
Brief Prenatal History
Important information regarding your current pregnancy
Childbirth Education classes taken, and techniques you found most helpful
Hopes and expectations of birth
*
Partner's hopes, fears, and expectations for birth
*
Birth Photography
professional, or other
Allergies
any known allergies to food, medications, etc.
Places you carry tension in your body
i.e. neck, shoulders, lower back, jaw, etc.
How you manifest stress or anxiety
racing heart, biting fingernails, clenched fists, etc.
Things you like about previous births, and what you would change
as applicable
Types of support that sound most appealing
select all that apply
Who will receive your baby?
person who will "catch" your baby
Requests for Placenta
Specialty Session
*
Select ONE specialty session of your choice
Photo Consent
*
Do you give Rewilding Birth permission to use your photo/story for marketing (i.e. social media, website, brochures, etc.)? We will always consult with you to make sure you are okay with us sharing, even if you select "yes".
Other preferences or instructions not already covered
Name and phone number for emergency contact
