Additional Form — Emergence Midwifery + Wellness

Thanks for considering Emergence Midwifery + Wellness for midwifery care for your pregnancy. We would love to get to know a little about you first.

Your Name

First Name

Last Name

Email

Your Partners Name

First Name

Last Name

What city do you live in?

First day of last menstrual period?

MM

DD

YYYY

Do you have a normal cycle?

Yes

No

Did you experience any complications during your past pregnancy, labor, birth, postpartum?

How are you feeling about this pregnancy?

Any significant health history that we should know about?

Yes

No

If so, please explain.

What interests you about midwifery?

How did you hear about Emergence?

Best number to reach you at?

(###)

###

####

Dates & times that work for you to schedule a complimentary consultation?

Current pregnancy concerns:

At Emergence Midwifery, all visits are conducted in your home. Our initial complementary consultation meeting, we meet virtually via Zoom or FaceTime.

Thank you for taking the time so we can get to learn more about you. We look forward to connecting so that you can learn more about the midwifery model of care, birthing in the comforts of your home, what care with Emergence looks like and what sets our team apart.

Blessings & Love,
Nancy, Caitlyn & Jess
The Emergence Midwives

Thanks for considering Emergence Midwifery + Wellness for midwifery care for your pregnancy. We would love to get to know a little about you first.

Explore

Connect