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Savage Maternity Clinic Appointment Form
 
Savage Maternity Clinic

At Savage Maternity Clinic, our mission is to provide the highest quality care for families and their loved ones. We are fully staffed and currently accepting new patients. Our team is dedicated to ensuring that your needs are met with professionalism and care, from pregnancy to post-delivery.

We work with trusted partners such as Hands On Mommy, Beyou, Poorterbuilt, Mama Alpha, Love Mommy, Really Needy, Eden, and MyStory to enhance your experience.

For more information, feel free to reach out to one of our trusted doctors. We’re here to assist you every step of the way.

Please Visit Our Website:
Savage Maternity Clinic Website

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Which Doctor would you like to coordinate your care for you? *
Full Name: Overhead and Legacy Name *

We’re excited to assist you in scheduling your consultation and tour at Savage Maternity Clinic. Please note, if you wish to request a specific doctor for your appointment, we kindly ask that you check with them first to confirm their availability, as each doctor has their own unique schedule.

Thank you for your understanding and cooperation. We want to ensure that your visit is as convenient and smooth as possible, so please reach out to the doctor or our staff to finalize your appointment.

We look forward to meeting you!


Important Clinic Policies

No Refund Policy
We do NOT offer refunds on any packages. Should you have an issue with our services, please direct your concerns to the Senior Doctor, КJ ÐΛ HłTTΛ SΛVΛGΞ SЯ M.Ð. 亗 (JadaDaGeminiMchs). If you choose to cancel services after payment, we will work with you to find a solution. Please be advised that our policy is strictly NO REFUNDS.

Missed Appointments and Deliveries
We understand that life happens, and sometimes appointments may be missed. If you are aware of a scheduling conflict, we kindly ask that you notify your doctor or an online staff member in advance.
Missed deliveries can be rescheduled based on the availability of your assigned staff member. Please note: If you miss two deliveries, your baby will be considered delivered, and in-clinic deliveries will no longer be available for you.

Important Restrictions
We do not accept requests related to miscarriages, abortions, or teen pregnancies. Savage Maternity Clinic reserves the right to end services, ban, or eject any individuals who engage in rude, disruptive, or foul behavior, as per the Terms of Service (TOS) regulations and SMC Policy. No refunds will be issued in these cases.

We appreciate your understanding and cooperation in adhering to our clinic policies. Our goal is to offer exceptional care in a professional and respectful environment for all our patients.

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Date and Time of your first appointment: *
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For single services select below: *
Required
Which package would you like to purchase? *
If you selected other, please explain: *
What type of birthing HUD do we have the pleasure to assist with? *
If other, for the Birthing Hud which Hud are you using?
If answered above, write N/A
*
Would type of birth would you like? *

Home Birth Assistance Request

If you are requesting a home birth, would you like to have a doula or midwife assist you with home visits or the home birth process?

If you choose a doula or midwife, please note that we will provide additional details and help coordinate with the appropriate professionals based on availability.

Thank you for your consideration and trust in our care.

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I hereby consent to the provision of diagnosis, care, and/or treatment by Dr. 亗 КJ ÐΛ HłTTΛ SΛVΛGΞ SЯ M.Ð. 亗 (jadadageminimchs) at Savage Maternity Clinic, and I hereby acknowledge that such consent will remain in effect unless and until I cancel such consent in writing.

I hereby acknowledge and confirm that I am mentally capable of giving informed consent to the provision of diagnosis, care, and/or treatment, and I am not subject to duress or undue influence.

I HEREBY ACKNOWLEDGE AND UNDERSTAND THAT, by signing this treatment care patient consent form, I am giving informed consent to the provision of diagnosis, care, and/or treatment by Savage Maternity Clinic. I further acknowledge that I cannot bring a tort or other similar action, including an action on a medical, dental, chiropractic, optometry, or other health-related claim, against Savage Maternity Clinic unless the action or omission of the hospital constitutes willful misconduct.

This form is a statement that you consent to receiving treatment from our physicians. It also confirms that you are aware of and have paid in full all fees associated with the intended care.

By signing below, I confirm my consent for the treatment and care as outlined, and I affirm that I have provided truthful information to the best of my knowledge.

Please inform the physician once this form has been signed. Thank you for trusting Savage Maternity Clinic with your care.



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