EmailMe Form - Hypnosis for Birth Registration

Name *

First Last

Due Date: *

Your Birthdate *

MM / DD / YYYY

Your preference:

Partner's Name

First Last

Partner's Birthdate

MM / DD / YYYY

Partner's Preference:

Your Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

How were you referred? *

Your Email *

Partner's Email *

Your Phone *

Partner's Phone *

Midwife/Doctor *

Doula

Where are you birthing at?

History of abuse/trauma/assault?

Any particular concerns or worries at this time?

By signing and submitting this form I acknowledge I am enrolling in this childbirth preparation by my own choice and with the understanding that this program is designed to teach me to use my own natural abilities to bring my mind and body into a state of relaxation with the purpose to facilitate the birth of my baby. I understand that the content in this preparation method is in no way intended to be represented as medical advice nor as a prescription for medical procedure, but rather educational in nature and intent.

Signature *

Clear