Midwifery Consultation

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I am fully booked for 2022 and I go on sabbatical the entire year of 2023! Currently I am only accepting estimated due dates in 2024.

The complementary consultation visits are scheduled for people desiring an out of hospital birth. I no longer offer doula services. I will spend 45 minutes to go over your home birth options. You may choose a virtual or in office appointment. Once you fill out this form you will receive an automated email with a link to schedule your appointment.

Consultations are free of charge and they do not substitute for prenatal care or medical advice. My schedule usually books 3-4 weeks in advance. If you have questions that need to be answered prior to the most available date, please email lamatrizbirth@gmail.com.

Once you fill out and submit this consultation , you will receive an automated response with the link to schedule your midwifery consultation.

I look forward to speaking with you!

Tema Mercado

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Name Name * First Last
Contact Phone Number *
Email *
Are you currently pregnant? *

Are you currently pregnant? yes no trying to conceive uncertain
Your Date of Birth Your Date of Birth * / MM / DD YYYY
Estimated Due Date (if pregnant) Estimated Due Date (if pregnant) / MM / DD YYYY
First day of last menstrual period First day of last menstrual period * / MM / DD YYYY
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Obstetric History *
Obstetric History	0	1	2	3	4	5	More+
Total # Pregnancies ?	Total # Pregnancies ?0	Total # Pregnancies ?1	Total # Pregnancies ?2	Total # Pregnancies ?3	Total # Pregnancies ?4	Total # Pregnancies ?5	Total # Pregnancies ?More+
# Vaginal Births?	# Vaginal Births?0	# Vaginal Births?1	# Vaginal Births?2	# Vaginal Births?3	# Vaginal Births?4	# Vaginal Births?5	# Vaginal Births?More+
# Cesarean Births?	# Cesarean Births?0	# Cesarean Births?1	# Cesarean Births?2	# Cesarean Births?3	# Cesarean Births?4	# Cesarean Births?5	# Cesarean Births?More+
How many children total?	How many children total?0	How many children total?1	How many children total?2	How many children total?3	How many children total?4	How many children total?5	How many children total?More+

I would like to discuss / explore the following: *

I would like to discuss / explore the following: Home Birth Prenatal / Postpartum Care only Pregnancy Body Balancing Other Other
Please tell me a little about yourself and why you are requesting a consultation *
If you have a PPO Health Insurance Plan, we can run a Verification Of Benefits (VOB) for $10. Would you like for us to run a VOB?
If you answered yes, please share the following:

Insurance Name
Insurance Plan Name
Group Number
Member ID
Insurance Subscriber Information
Front of Insurance Card

Attach Files
Back of Insurance Card

Attach Files
How did you here about La Matriz Birth Services? *

How did you here about La Matriz Birth Services? Online web search Yelp Social Media Friend Other Other

Midwifery Consultation

Midwifery Consultation

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