Name of Birthing Parent * First Name Last Name Preffered Name (If different from above) Birthing Parents Date of Birth MM DD YYYY Phone (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Partner or Support Person's Name * First Name Last Name Partner's Phone * (###) ### #### Partner's Email Relationship to Birthing Parent? Do you have any other children? EMERGENCY CONTACT INFORMATION Emergency Contact First Name Last Name Emergency Contact Phone Number (###) ### #### Emergency Contact Relationship HEALTH CARE PROVIDER INFORMATION Name of Care Provider First Name Last Name Type of Provider OBGYN Midwife Other Phone Number of Provider (###) ### #### Location where you plan to deliver Hospital Birth Center Home Address of planned delivery location Address 1 Address 2 City State/Province Zip/Postal Code Country If planning for a home birth, do you have a backup hospital location? Which hospital? CURRENT PREGNANCY INFORMATION Baby's Estimated Due Date MM DD YYYY Gender of the Baby Girl Boy Surprise Preferred Method of Birth Vaginal Cesarean Birth Vaginal Birth After Cesarean (VBAC) Elective Induction Induction for Medical Reasons Water Birth Other In this current pregnancy, have you had any pregnancy-related health conditions of which we should be aware? Do you have any general concerns or questions we can address for you? Thank you!