Class enrolment form Class Date * MM DD YYYY Mothers Name * First Name Last Name Partner/Support persons name First Name Last Name Address Phone Email * What services are you interested in? * Birth, Baby, You...Group Antenatal Course The Confident Birth Course Occupations Health Fund Details Do either of you have any specific fears or phobias (e.g. water, heights, etc.)? Are you or your partner currently being treated for any medical or psychological issues? Do you take medication/s on a regular basis? If yes, what medications do you take? What birth is this for you? Due date MM DD YYYY Model of Care: Private Obstetrician/Private Hospital Private Obstetrician/Public Hospital MGP/Public Hospital MGP/Birth Centre Independent Midwife/Home Birth Independent Midwife/Hospital GP Shared Care/Public Hospital Other Do you have any concerns or fears regarding the birth and parenting? What would you like to get out of the program How did you hear about the Classes? Word of Mouth Social Media Doctor Midwife Internet Other Do you give permission to use any of your photos, testimonials and birth stories for print and online marketing? Yes No Disclaimer: I understand that the class uses deep relaxation tools to assist in the birth and parenting process. * Yes Thank you! I will be in contact soon to discuss your needs.
