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Casey Toth ✽ B I R T H  W I T N E S S ✽ Reservation Form
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Name
Email address
Phone number
Partner's name
Partner's email address
Partner's phone number
What is your preferred method of communication?
Address
Estimated forty weeks date
Describe your birth support team
Describe your experience of this pregnancy so far, history of your previous pregnancies and births, and your vision for this birth.
Select your imagery package(s)
Describe any ideas you envision for your imagery and/or provide links to examples of work you are drawn to.
Please select your pricing tier based on your household income
What is your preferred method of payment?
I understand a minimum non-refundable deposit is due upon reservation.

Tier 1: $400
Tier 2: $480
Tier 3: $560
Tier 4: $640
Clear selection
I understand there are potentially additional costs involved:

• Cost to travel to homes farther than 60 minutes
• Cost to request shorter editing deadlines than originally offered
• Cost per day for births lasting longer than 24 hours

Tier 1: $140
Tier 2: $180
Tier 3: $220
Tier 4: $300
Clear selection
I understand the remainder of my balance is due upon entering 'on call' three weeks before your estimated forty weeks date. 

Clear selection
I understand Casey Toth is not a licensed medical provider, and cannot provide medical advice or perform medical services.


Clear selection
I understand I must notify Casey Toth in a timely manner in advance of when I expect her to arrive at my birth considering the drive time. It is up to me to decide at what point in my labor I want her to join me.

Clear selection
I understand failure to provide Casey Toth notification of early active labor in a timely manner, resulting in missing the birth, is not a valid request for receiving a refund and your remaining balance is still due.


Clear selection
I understand if with proper notification Casey Toth fails to provide services due to an unforeseen emergency, I will receive a full refund of my remaining balance.

Clear selection
Please add anything else I should know in order to best support you.


How did you find me?


Please type your full name and the date as a digital signature confirming your understanding of and agreement to the terms described above and that all information is correct.

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