Birth Questionnaire


Thank you for taking the time to fill out this questionnaire. Your responses will help better understand your unique situation.

Mother's Name *
Mother's Name
Mother's Primary Phone *
Mother's Primary Phone
Mother's Secondary Phone *
Mother's Secondary Phone
Mother's Birthday *
Mother's Birthday
Primary Support Person *
Primary Support Person
Support Person's Phone *
Support Person's Phone
Due Date *
Due Date
Note: Dr. Patty, Dr. Jones & Dr. McSpadden usually allow photography. But double check for your specific case.
Address of the hospital/birthing location
Address of the hospital/birthing location
Not required for Poplar Bluff Regional Medical Center.
Note: Poplar Bluff Regional Medical Center allows both nautral birth and c-section photography.
Births rarely go perfectly according to plan. But please give me as many details as you can about how you expect your child’s birth to take place. (Vaginal/Planned C-Section, Hospital/Birthing Center/Home, Medicated/Natural, Bottle/Breastfeed, Immediate Skin to Skin etc.)
No image containing genitalia will be released publicly (facebook/ website etc) without your consent (and even then, typically cropped to obscure the face so that you’re not identifiable).
How did you hear about Artist By Heart Birth Photography? *
Less than one email per month and no spam.

Thank you for your submission!