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Today's Date:               


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Due Date:
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Expectant Mother's Name:
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Age:
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Address:
City/Town:____________________________________________________________

Province:_____________________________________________________________

Postal Code:___________________________________________________________

Phone:

Days: ____________________________________________________________________

Evening: __________________________________________________________________
Email:
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Occupation
(Current or Past)

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Names & Ages of Other Children

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Briefly Describe Previous Birth Experience(s)


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Labour Partner's Name:
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Age:
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Phone:
Day:____
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Evenings:
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Occupation
(Current or Past):
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How did you learn about Birth & Beyond classes?

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Midwife/Doctor's Name:
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Baby's Doctor:
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Where do you plan to give birth?  
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Are you planning on having a Doula at your birth? Yes: No:
What is your choice for feeding?

Breast:
Bottle:
Combination:
Do you have an infant car seat?
Yes:
No: 
Describe any conditions (medical or otherwise)
you feel your educator should be aware of:

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What is your greatest concern about this pregnancy, labour and birth?
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What do you hope to gain from these classes?
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Class Size is Limited so Please Submit This Form With $65 Non Refundable Deposit Fee to Hold Your Spot to:
Mélissa Cowl, 4257 Concession 5, R.R. #2,
Loretto, ON L0G 1L0.

If you have any questions please feel free to contact Mélissa at 705.435.3715 or doula@sympatico.ca