STREAM Session

Hello and thank you for visiting my site. Please help me understand how I can serve you best by filling out this form as fully as possible.

Warmly,

Midwife Tema

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Name Name First Last
Contact Phone Number
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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 with STREAM work:

I would like to discuss / explore the following with STREAM work: Well Womb Care & PAP's Vulva Mapping Breach Body Balancing Miscarriage Healing Therapies Pregnancy Body Balancing Childbirth Injuries Incontinence Abdominal Seperation Organ Prolapse Painful Intercourse Scar remediation Birth Rehearsal other Other Other
Please tell me a little about yourself and why you are requesting a consultation
Payment for Stream Session is $199. If you are a current Midwifery Client receiving midwifery care from me your special pricing is $145. You will have an option to pay via Paypal with this registration system or you may pay at our visit.

Payment for Stream Session is $199. If you are a current Midwifery Client receiving midwifery care from me your special pricing is $145. You will have an option to pay via Paypal with this registration system or you may pay at our visit. Midwifery Client Pricing $145 STREAM Session Full Payment $199 I'll pay cash or by check at appointment.
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 MagaMama Other Other

STREAM Session

STREAM Session

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