CONSULTATION FORM

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Vita Nova

This short intake form helps me learn a bit about you, your pregnancy, and your hopes for birth so I can prepare for our consultation. All information is kept private and is only used for your care with Vita Nova Midwifery.

Once you submit the form, I’ll be in touch to schedule your visit and talk through next steps.

Please fill out the following form.

First name

Last name

*Email

Date of birth

Day

Month

Year

*Are you currently pregnant?

Yes

Estimated Due Date:

Leave blank if not applicable.

*Is this your first pregnacy?

Yes

*Number of prior births? (if any)

*Have you had a prior homebirth?

Yes

*Where are you currently receiving prenatal care (if anywhere)?

*Have you ever been told you have a high-risk pregnancy or major health condition (heart disease, severe hypertension, etc.)?

Yes

Have you ever been told you have a high-risk pregnancy or major health condition (heart disease, severe hypertension, etc.)?

*How did you hear about Vita Nova Midwifery?

Friend or family

Google / online search

Social media

Professional Reference

Other

*Is it okay for me to contact you by phone, text, or email about scheduling a consultation?

Yes

I understand that many insurance companies do not cover out-of-hospital birth and it is my responsibility to contact my insurance company about coverage and reimbursement.

*Initials

I declare that the info I’ve provided is accurate and complete.

Still have questions?

I’m happy to help. Send me a message with your questions, and we’ll talk through whether homebirth care with Vita Nova Midwifery is the right fit for your family.

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