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Charm City Midwives Information Session Questionnaire
Thank you for your interest in Charm City Midwives! This Info session will be to
introduce our practice to you. Please fill this out so we have an idea of who you are and what you’re looking for!
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What is your name?
Your answer
What is your email address?
*
Your answer
What is your due date?
Your answer
Which number baby are you expecting?
Your answer
Where do you live?
Your answer
What health insurance do you carry?
Your answer
Why are you interested in homebirth?
Your answer
Have you had a homebirth before?
Your answer
What questions do you have about homebirth, midwifery care, our roles and responsibilities, training, etc.?
Your answer
What do you envision your homebirth will look like?
Your answer
Any significant history from your previous pregnancies, health history, surgeries, etc. that we should know about? (c-sections, medical issues)
Your answer
How does your partner or other family, friends or your planned birth supporters view homebirth?
Your answer
Any fears, concerns, or other questions you’d like to discuss?
Your answer
What are you hoping to gain from this info session?
Your answer
How did you hear about us?
Your answer
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