Mother's Name
*
First Name
Last Name
Mother's Email
*
Mother's Primary Phone
*
(###)
###
####
Mother's Secondary Phone
*
(###)
###
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Mother's Birthday
*
MM
DD
YYYY
Primary Support Person
*
First Name
Last Name
Support Person's Relation to Mother
*
Support Person's Phone
*
(###)
###
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Due Date
*
MM
DD
YYYY
Will this be your first birth experience? If no, please note how many babies you've delivered and whether they were natural or via c-section.
*
How many babies are you expecting?
*
one
two
more than two
If known, what is baby's gender and name?
*
Name of your care provider
*
Is there any reason for your care provider to think that you may go into labor before or after your due date? If so, what is the reason and when do they suspect you will give birth?
*
Do you have a history of going into labor early, having especially fast births, or having medial complications? Please explain.
*
Have you had any complications during this pregnancy?
*
Name of the hospital/birthing location
*
Address of the hospital/birthing location
Not required for Poplar Bluff Regional Medical Center.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What is your personal birth plan?
*
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.)
Do you plan to be induced if baby doesn't arrive by a certain date? Please explain.
*
Who do you plan to attend the birth? Please list names and relation to you.
*
How do you respond to the following statements?
*
Documenting my beautiful and unique Birth Story is very important to me.
It is my desire that Jennifer, specifically, document my Birth Story.
I will cater your birth photography to your modesty and comfort. For example: Many mothers want crowning images, while some mothers would prefer images from the head of the bed during crowning. Please list below any requests that pertain to modesty.
*
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).
If you have a preference, which specific elements of the labor and birth would you like captured?
Would you like me to leave the room for particular exams?
I require a Model Release Form because it allows me to demonstrate to future clients the standard of work I create. Would you be willing to sign a Model Release Form?
*
Yes
Yes, but I need more information
No
Are there any additional notes you would like to give the photographer?
How did you hear about Artist By Heart Birth Photography?
*
