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Pre/Post Natal Class Consultation Form
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Name (First & Last):
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Your answer
Phone Number:
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Your answer
Email:
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Your answer
Address & Zip Code:
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Your answer
Care Provider's Name and Number:
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Your answer
Current Medications and Health Status:
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Your answer
When is your Due Date?
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MM
/
DD
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YYYY
Number of previous deliveries and any unique circumstances:
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Your answer
Where are you planning to have your baby?
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Your answer
Have you had any complications with this pregnancy? Please describe.
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Your answer
Who is your Support Person? Name & Relationship.
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Your answer
What times and days are you available for classes?
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Your answer
Would you like to share the sex and/or name of your baby?
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Your answer
Please select the classes you are interested in taking:
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Lamaze (6 Classes)
Condensed Lamaze (3 Classes)
Labor Rehearsal
Breastfeeding
Newborn Care
Required
If your are taking our Lamaze or Condensed Lamaze Classes, what is your preferred method of payment?
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Lamaze: One time payment of $599
Lamaze: Pay Per Class. Each class is $119 (6 Classes)
Condensed Lamaze: One time payment of $299
Condensed Lamaze: Pay Per Class. Each class is $138 (3 Classes)
Not applicable to me
Do you have any questions or concerns in regards to your pregnancy, the classes, method of payment, etc.?
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Your answer
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