Pregnancy Screening Form
Name: *
Your answer
Address: *
Your answer
Telephone:
Your answer
Email:
Your answer
Is this your first baby?
Your answer
How many weeks pregnant are you?
Your answer
Estimated due date?
MM
/
DD
/
YYYY
Emergency Contact:
Your answer
Their relationship to you?
Your answer
During this pregnancy, have you experienced the following - please select ALL that apply:
Why are you attending this class and what do you hope to gain from it?
How did you hear about this class?
Are you interested in the following? *
Required
Please check this box to let me know that you agree to me contacting you by email with details of my classes and services and to notify you of any changes to class times or cancellations.
DATA PROTECTION: Please check this box to confirm that you understand that Kim Jones Wellbeing will hold the personal information you provide here securely and will not share this information with any third parties without your prior consent. *
Required
Please let me know if you are happy to receive my newsletter and details of events that I am running by email. *
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