Breath of Life Midwifery

Take Back Your Birth!

New Clients Required Forms


To Be Completed Upon Initiation of Care by All Clients


Client Intake and Medical History: https://form.jotform.com/61000311716134
Informed Disclosure Agreement: https://form.jotform.com/80015367325148
Emergency Care Plan https://form.jotform.com/53095842421151
VA High Risk Disclosure Form https://form.jotform.com/53536516246154

Financial Agreement

Financial Agreement - Self Pay: https://form.jotform.com/80015398125150
Financial Agreement - Medicaid: https://form.jotform.com/80015220425137

VA Required Disclosures (Only complete those that apply to you.)
Between 24 and 30 Weeks

Gestational Diabetes Screening: https://form.jotform.com/53097274770159

At 36 Weeks