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HypnoBirthing Group Class Registration for April 13-May11
This class will be located at The Space, 316 W 33rd St, Edmond, OK 73013 and will begin at 6pm.
Thank you for taking the time to fill out this information! If you have any questions, let me know by email at
doula.jen.miller@gmail.com
or by phone/txt- 954-579-1406
Blessings,
Jen Miller
HypnoBirthing Educator
Birth Doula
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Email
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Your name
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Your Pronouns (ex: she/her, he/him, it/they, etc)
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Phone Number
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Your answer
Address
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Your answer
Birth Companions Name and relationship to birthing person (If applicable, who will be your primary support and attending classes and/or birth with you? This may be a spouse/partner, family member, doula, etc.) A birthing companion is recommended, but not required.
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Your answer
Birth Companion's Pronouns (ex: she/her, he/him, it/they, etc)
Your answer
Birthing Companions email address and/or phone number.
Your answer
Estimated Due Date and/or current gestation in weeks (i.e. I am currently 27 weeks pregnant)
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Have you birthed before?
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Where do you plan to birth?
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Who is your care provider? (Give name of OB or midwife or other provider)
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Is there anything I need to know about you, your pregnancy, or upcoming birthing to better serve you? (i.e. high risk status, illness, anxiety/depression, injury, VBAC, multiples, trauma, etc.)
Your answer
How did you hear about HypnoBirthing and/or Miller Birth Services?
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Preferred method of contact
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Course Agreements and Consents
Please select "Yes" or "No" The HypnoBirthing Institute may contact you for quality assurance and research purposes. If you consent to be contacted now, please note that you are free to change your mind at any time. Be assured that we will not share your personal identifying information with anyone outside the HypnoBirthing Institute for any purpose. Thank you for your help in collecting data to support the growth of HypnoBirthing ®.
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Please select "Yes" or "No" Permission to Use Images Subject: The HypnoBirthing Institute/Miller Birth Services- HypnoBirthing and Doula photos and video. I grant to Jennifer L Miller and/or Miller Birth Services, its representatives and employees the right to use images of me/us/our baby in connection with the above-identified subject. I authorize Miller Birth Services, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that The HypnoBirthing Institute and/or Jennifer L Miller and/or Miller Birth Services may use such images of me/us/our baby without identifying information unless permission given to include such information and for educational and promotional purposes. I have read and understand the above:
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Please type your name and the date to indicate your signature on this form. I hereby state that I am enrolling in the HypnoBirthing class of my own free will and with the understanding that this is a program designed to teach me to use my own natural abilities to bring my mind and my body into a state of relaxation. I further understand that the content of these classes is in no way intended to be represented as medical advice nor as a prescription for medical procedure. I am aware that I should seek the advice of a health-care provider to answer any health-related or pregnancy-related issues surrounding my pregnancy, my labor, or my birth. I therefore agree that I will in no way hold the instructor of the HypnoBirthing classes, or the HypnoBirthing Institute, its owner, or its representatives responsible for any special circumstances that could arise as a result of my pregnancy, my labor, or the birth of my child; and I agree that neither I nor any member of my family will make any claim or initiate any suit against any of the above-named parties now or at any time in the future.
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