THREERINGSMIDWIFERY Email Marketing -

Home Birth Consultation Application

The following form helps the Three Rings Midwife prepare for your consultation. Once the application is submitted, you will receive a welcome email with additional information.

First Name

Last Name

Email*

Phone

Date of Birth

How did you hear about us?*

Estimated Due Date (unknown? Enter today's date)*

Have you started to receive prenatal care?*

If so, where? Include system and/or provider's name as applicable.

How many vaginal births have you had?*

How many Cesarean Sections have you had?*

Why are you interested in having a home birth with Three Rings Midwifery?*

Many folks are told or interpret what they have or have had a High-Risk pregnancy. I find often after review of history that this is not the case. Do you believe that you have a high-risk pregnancy?*

If yes, please explain why?

On a scale of 0-10, with 10 meaning extremely motivated, how motivated are you to have a home birth this pregnancy?*

Which of the following represents your financial ability to invest in your pregnancy right now?*

I am willing and able to invest whatever it takes to have the home birth I desire.

It would be a stretch for me but I'm willing to make it work given the right options.

I am not in a position to financially invest in my pregnancy related care right now.

Do you need to consult with a partner, family member or any other person to make financial decisions?*

If yes, will the person that you consult with be present at the time of the consultation.*

I understand that by submitting this application, I am also agreeing to have my email added to Three Rings Midwifery promotional and newsletter email lists.*

I agree.

I do not agree.