HypnoBirthing Clients
Please fill out this form before our first HypnoBirthing session.  I am so excited to work with you!
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Today's date *
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Full Name *
Mailing Address *
Date of Birth *
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Contact Phone Number *
Email Address *
Do you want to receive clinic information, including news, events and health tips by email? *
Date of last known menstrual period *
Name of Birthing Companion and relationship to you *
Is there anything important that you want me to know about your pregnancy?
How did you hear about my HypnoBirthing classes?
All information collected by this office, remains in this office. Files are placed in a locked cabinet and can only be accessed by Dr. Joanna Thiessen and her personal staff. All information contained in the practice including telephone conversations, correspondence and files are privileged information and cannot be released, copied or discussed without the prior written consent of the patient. Staff are aware of personal identifying information only. They pull and file records as required. *
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