Birth Lactation Contract

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Mom's Name *

First

Last

Baby's Due Date *

Birth Location *

Care Provider *

Mom's Cell Phone Number *

Mom's Email *

Dad's Name *

First

Last

Dad's Cell Phone Number *

Dad's Email *

Mom's Age *

Previous Pregnancies *

Number of Living Children *

Ages of Living Children *

Previous Births *

Any Complications in Previous Pregnancies *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Please explain complications *

Referred By *

Additional Comments/Questions *

Role as Birth Lactation Consultant: As your Lactation Consultant I educate you so you are well-informed about breastfeeding and therefore have the confidence to make the best decisions for you and your baby. I assist you after baby is born to help ensure a satisfying breastfeeding experience & outcome. I draw on my education and experience to provide emotional support of breastfeeding.

I am available to you by phone and email for questions throughout your pregnancy and after you have given birth. I am there to provide evidence-based information from resources such as The World Health Organization (WHO), and the American Academy of Pediatrics (AAP).

When to contact me: Please contact me by text or phone when you lose your mucus plug. That is a pretty good indicator that labor might start within the next few days. If it is the middle of the night and you have delivered the baby please don’t hesitate to call; I work for you so I will be able to wake & join you. However, if you need me during the labor, please call me. I will stay in touch with you by phone until you have delivered the baby and are ready for my help. Please allow approximately 30-45 minutes from the time you ask me to join you for me to arrive at the hospital. So you might want to give me another heads up when active labor starts so I can get ready sooner.

Fees

Fees: My fee for the services described is $500 to be paid 50% at the time of entering into the agreement (an invoice will be sent to your email). The other 50% is due at 36 weeks (you can pay this by invoice or in person)..

Refunds

The policy of refund of payment is as follows:
Cancellation policy: If at any time you feel you need to terminate this contract you will pay as follows be timeline: More than 2 months before delivery you will pay $230

Less than 2 months before delivery you will pay $340

In signing this Contract, you agree that you have read and understand the Service Descriptions and Agreement for Oh Baby Mine Placenta Encapsulation Service and that you agree to the terms and conditions outlined therein, as well as the stated fee.

By Checking This Box You Agree That All the Above Information is True *

All of the Above is True

By submitting this form with my legal name I am providing my signature *

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