Virtual Birth Doula Agreement Form
Date
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Month
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Day
Year
Date
Mother's Information
Name
First Name
Last Name
Age
Date of Birth
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Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Estimate Due Date
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Month
-
Day
Year
Date
Planned Birth Location
Hospital
Home
Birth Center or Lying-in
Select a communication method
Google Meet
Zoom
Skype
Facebook Messenger
Email
Phone
Text
Other
Partner's Information (Father)
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Payment Details
Available package
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next
( X )
Bronze Package
Bronze package includes Doula services.
$
500.00
Silver Package
Silver package includes Doula services and documentary photos and videos.
$
900.00
Gold Package
Gold package includes Doula services, photos, videos, and post-operative follow-up.
$
1,200.00
Payment Method
Credit Card
Check
Cash
Wire Transfer
Bank Transfer
Purchase Order
Other
Comments, suggestions, or feedback
Terms and Agreement
Please check if you agree to the following:
I confirm that my doula will provide emotional and physical support before and during my normal labor using methods without any medications.
I understand that my Doula will no give medical advice or do any medical procedures.
I confirm that my Doula will not be responsible for taking my vital signs, prescribe medications, perform vaginal exams, or treat any complications.
I understand that my doula will not make decisions on the mother's behalf.
I understand that my doula will not speak directly to the medical or health care staff on my behalf.
I authorized a back-up doula if the assigned doula is not available.
I give my doula permission to post photos on their social media or website as long as it is for good intentions and with an appropriate disclaimer. Please do not check this if you wish not to be posted on our social media page or website.
I release my doula and the company she belongs to any responsibility or liability on me or my baby for any harms, incidents, or any related issues that might happen during my labor.
I give permission to my doula to take notes about me that might include personal information related to my pregnancy. This information should be strictly confidential and can only be used for internal studies.
Mother's Signature
Date Signed
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Month
-
Day
Year
Date
Submit
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