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Request for Consultation
In order to request information or a consultation to Harvest Midwifery regarding midwifery services, please fill out this form in its entirety. Please note: We may not be able to respond immediately. If you do not receive a response within 5 business days, our midwives may be with other mothers in labor or tending to the needs of our families. We appreciate your patience.
Consultations will only be offered if a FULL address is provided, is within our service range (within 45 minutes of Harvest, AL), and we still have availability for your due date.
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Email
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Your email
Legal Name
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Your answer
Street Address
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City
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State
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ZIP
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Phone Number
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Your answer
Date of Birth
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First day of last menstrual period
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Estimated due date (if known)
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Height
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Pre-pregnant weight
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Current weight
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How many times have you been pregnant, including this pregnancy?
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Your answer
Describe the foods you eat on a regular basis. (Check all that apply.)
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Animal protein (beef, lamb, pork, venison, chicken, eggs, etc)
Seafood (fish, shrimp, etc)
Plant protein (beans, chickpeas, lentils, tofu, etc)
Dairy products (milk, yogurt, cheese, sour cream, etc)
Leafy green and other low-starch vegetables (greens, broccoli, bell peppers, asparagus, tomatoes, squash, Brussels sprouts, etc.)
Starchy vegetables (potatoes, carrots, other root vegetables)
Grains (wheat, corn, rice, etc)
Fruits and berries (apples, oranges, peaches, strawberries, raspberries, blueberries, etc)
Sweets (natural or artificial; cookies, cakes, ice cream, etc)
Gluten-free
Dairy-free
Vegetarian
Vegan
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How many births have you had prior to 37 weeks gestation? Please explain at what gestation each baby arrived (if applicable).
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Your answer
How many births have you had after 37 weeks gestation? Please explain at what gestation each baby arrived (if applicable).
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Your answer
Have you had prior prenatal care this pregnancy? If so, with whom?
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Major medical history/diagnoses (includes anxiety, depression, hypothyroid, high blood pressure, epilepsy, etc)
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Current medications/supplements (please include dosages and how long you have been on the medication/supplement for each one)
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Past pregnancy/birth complications (includes pre-eclampsia, gestational diabetes, postpartum hemorrhage, cesarean delivery, etc)
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