My Powerful Birth Intake


Here is a copy of the My Powerful Birth Service Agreement*

Michelle Tyliakos
mt@crowningglorydoula.ca


Name *
Name
Phone # *
Phone #
include buzzer number if necessary
Guess Date *
Guess Date
Partner's Name (if you have one)
Partner's Name (if you have one)
Partner's Phone
Partner's Phone
Birth Information
If your current care provider isn't your first choice please state who would prefer.
Hospital or homebirth? And state if you are still deciding about location
Are there any steps that you are taking to improve your nutritional Status?
What types of physical activity are you taking part in?
I have read The Service Agreement. (link above) *