Birth Plan Template
Mother’s Name
First Name
Last Name
Due Date
-
Month
-
Day
Year
Date
Age
Health Care Provider/Insurance Name
Policy number
Birth Method Preferred
Baby's Name
Baby’s Gender
Male
Female
Birth Companion
Yes
No
Preferred Midwife Name
First Name
Last Name
Preferred Midwife Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Institution (Hospital, clinic, lying-in, etc.)
Preferred Birth Position
Birth stool In bed
Kneeling
Standing
Water birth
Sitting
Squatting
Birth ball
Side-lying
Other
Would you like to receive pain relief?
Yes
No
If needed, which method do you prefer?
Forceps
Ventouse
Any
After delivery (when baby comes out and the umbilical cord is cut), would you like to happen?
Put baby in your tummy
Clean the baby first
In terms of providing Vitamin K, how would you like to be administered?
Orally
Intramuscular (injection)
Feeding method
Breast feeding
Formula method
Any special instructions, feedback, or suggestions?
Mother's Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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