Request for Consultation
In order to request information or a consultation to Harvest Midwifery regarding midwifery services, please fill out this form in its entirety. Please note: We may not be able to respond immediately. If you do not receive a response within 5 business days, our midwives may be with other mothers in labor or tending to the needs of our families. We appreciate your patience.

Consultations will only be offered if a FULL address is provided, is within our service range (within 45 minutes of Harvest, AL), and we still have availability for your due date.
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Email *
Legal Name
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Street Address
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City
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State
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ZIP
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Phone Number
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Date of Birth
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First day of last menstrual period
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Estimated due date (if known)
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Height
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Pre-pregnant weight
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Current weight
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How many times have you been pregnant?
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How many births have you had prior to 37 weeks gestation? Please explain at what gestation each baby arrived (if applicable).
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How many births have you had after 37 weeks gestation? Please explain at what gestation each baby arrived (if applicable).
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Have you had prior prenatal care this pregnancy? If so, with whom?
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Major medical history/diagnoses (includes anxiety, depression, hypothyroid, high blood pressure, epilepsy, etc)
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Current medications/supplements (please include dosages and how long you have been on the medication/supplement for each one)
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Past pregnancy/birth complications (includes pre-eclampsia, gestational diabetes, postpartum hemorrhage, cesarean delivery, etc)
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