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Natural State Doulas
Childbirth Class Registration Form:
Hello! We're so honored to support you as you prepare to welcome a new addition to your family. We know that preparing for this special time can bring many questions and concerns, and we're proud to provide evidence based information and resources, and to support you as you make the best decisions for your family. Once registered you'll receive an email regarding payment options and class details.
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Mother's Name:
Your answer
Partner/Support Person's Name:
Your answer
Mother's Cell Number:
Your answer
Coach's Cell Number:
Your answer
Mother's e-mail address:
Your answer
Mother's mailing address:
Your answer
Preferred method of contact:
Phone
E-mail
Text
Other:
Estimated Due Date:
MM
/
DD
/
YYYY
Midwife/OB/Doctor:
Your answer
Birth place:
Your answer
Will this be your first birth?
Yes
No
Clear selection
If no, please give a brief description of any previous childbirth experiences: (Vaginal, Cesarean, Unmedicated, Medicated, etc)
Your answer
Are you expecting twins?
Yes
No
Other:
Clear selection
Any known complications with your pregnancy so far?
Yes
No
Clear selection
If so, explain:
Your answer
How did you hear about these classes?
Your answer
What are you most interested in learning during these classes?
Your answer
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