Earthside Interest Form
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Please fill this out completely if you would like us to contact you about getting started with care at Earthside Birth and Wellness, or for other information. We are a self pay only facility. Our midwives are Out-of-Network providers for most major insurance companies and we can provide you with a superbill after your birth to submit to them for reimbursement. We offer a sliding scale discount on our birth services with qualifiers of having  Medicaid or Tricare Insurance. 
The following are basic risk factors that would exclude you from birthing at Earthside Birth and Wellness: 
- Under 16 years old
- Hypertension
- Pre-eclampsia
- Eclampsia
- Multiples (twins, triplets, etc)
- Placental Abnormalities, including previa or abruption
- Post-maturity labor (past 42 weeks)
- Previous C-Section
- Known Breech or other non-vertex presentations
- Current use of non prescription drugs/Marijuana
- Currently smoking with no intention of stopping
- You are 32 weeks pregnant or more and have not had any prenatal care

Please type your name below to acknowledge you have read these risk factors and that you do not have them.
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How did you hear about us? *
First and Last name *
Today's Date *
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Phone *
Email *
Your Birthday *
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Are you currently pregnant? *
Estimated Due Date
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How many children have you birthed? *
Were there any complications with any of your previous births? If so, please explain.  *
Do you have insurance?  *
We schedule our Earthside Center Tours on Tuesday mornings at 10:30 and Thursday afternoons at 1:30. Please schedule your tour through our Calendly link. *
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Thank you for your interest. Please add any other information you feel it would be good for us to have before we proceed with scheduling care.
If you are not pregnant and are just looking for information/connection with Earthside Birth and Wellness Center, please leave us a message below and we will get back to you within 5-7 business days. 
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