Breath of Life Midwifery

Take Back Your Birth!

New Clients Required Forms


To Be Completed Upon Initiation of Care by All Clients

Client Records Release: https://form.jotform.com/62455135050144
Client Intake and Medical History: https://form.jotform.com/61000311716134
Informed Disclosure Agreement: https://form.jotform.com/53095935163157
Practice Guidelines: https://form.jotform.com/53098113346151
Emergency Care Plan https://form.jotform.com/53095842421151

VA Required Disclosures (Only complete those that apply to you.)
Financial Agreements

Financial Agreement - Self Pay: https://form.jotform.us/70987297872174
Financial Agreement - Medicaid: https://form.jotform.us/70986965672173
Medicaid MCO Exemption Form: https://form.jotform.com/53055423499157

Between 24 and 30 Weeks

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

At 36 Weeks