Virtual Birth Doula Agreement Form

Virtual Birth Doula Agreement Form
Date
MonthDayYear
Date
Mother's Information
Name
First NameLast Name
Age
Date of Birth
MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Estimate Due Date
MonthDayYear
Date
Planned Birth Location
Select a communication method
Other
Partner's Information (Father)
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Payment Details
Available package
prevnext( 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

Total
$0.00
Payment Method
Other
Comments, suggestions, or feedback
Terms and Agreement
Please check if you agree to the following:
Mother's Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

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