Doula Support Class

Class: Doula Support Class

Times: By appointment only – 2 1/2 hours

When should I take my class?

Price: $75  PER 1 Doula and 1 Couple

Prices may change without warning

No class registration will be accepted when a chosen class date is within 15 days of the due date.

** Payment is due at time of registration *

Customer Testimonial:

“I took the Comfort Measures class just weeks before the birth of my son, and found all the tips and advice Lisa provided to be so very helpful. I wasn’t sure if I would be able to deliver naturally because of complications, and Lisa helped walk me through a variety of scenarios I might encounter.

All went well at the time of birth, and I was able to make it through labor and delivery naturally, but I recognize that this would not have been possible without the help and advice Lisa provided. She was very kind and personable, and I highly recommend her!”

Elizabeth & Ben

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ALL CANCELLATIONS MUST BE MADE AND CONFIRMED 14 DAYS PRIOR TO CLASS START

How did you hear about the class:*

Yelp

Google

Internet

DC Urban Moms

Birth Options Alliance

Doctor/Physician

GW Midwives

Midwife

Doula

Other

Other Referral:*

Who referred you to the class, or Doctors name?

Class Location: Online

Doulas Name:*

First Last

Doulas Email:*

Doulas Phone:*

Doulas Address

Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

Mothers Name*

First Last

Email:*

Phone:*

Father/Birth Partners Name:

First Last

Email 2:

Phone 2:

Parents Address

Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code

# of people attending class:*

1 person

2 person

3 person

Which class are you registering for:*

Doula & Comfort Techniques

Choose the PRE-AUTHORIZED class date appointment:*

DD slash MM slash YYYY

Date CANNOT be prior to or the same date as the date of registration!

Annotate the PRE-AUTHORIZED class time appointment:*

Hours

:

Minutes

AM PM AM/PM

Due Date:*

DD slash MM slash YYYY

Cannot be prior to today.

Physician:*

Dr. ??

Delivery Hospital:*

Hospital ??

HIGH RISK PREGNANCY FACTORS: (IVF, twins, preeclampsia, diabetes, chronic hypertension, complications, medical considerations, etc..)*

???, none

EXISTING MEDICAL CONDITIONS: Examples – Hypoglycemia, hypotension, previous head injuries, neurological problems, back injuries, heart condition(s), chronic illness(es), chronic injuries, history of fainting, etc..*

???, none

Notes

Add a comfort kit – $25 (plus Postage/S&H if mailed; within the Virginia/Washington DC/Maryland region – is approximately $9.30)  ** If ordered at time of registration, or prior to your class materials being mailed for your class, the shipping of class materials and the comfort kit can be combined, this drastically reduces the mailing cost of the comfort kit to approximately $2.25 (more if it is shipped outside the DC Metro area).

Class Payment Options:  On-line with Stripe (credit cards), PayPal, Zelle, Cash, or Money Order

Comfort kit Payment Options: May also be purchased using Venmo; @BirthingBasicsLLC, last 4 phone digits = 2044

Contact dan@birthingbasics.com with any payment questions (please include a phone number as well as return email address)

** Payment is due at time of registration **

Prices may change without warning

  Payments; dan@birthingbasics.com

Billing Address*

Street Address City State / Province / Region ZIP / Postal Code

Classes*

**Choose the Corresponding Class/Classes Combination and Payment Amount**Advanced FHM – $150.00Comfort Kit – $25.00Comfort Measures Mil & Comfort Kit – $97.00Comfort Measures Mil Discount – $72.00Comfort Measures/Refresher + Comfort Kit – $105.00Comfort Measures/Refresher class – $80.00Doula Support Class – $75.00Doula Support Class & Comfort Kit $100.00Group & Comfort Classes + Comfort Kit – $232.00Group & Comfort Measures Classes – $207.00Group & High-Risk & Comfort Kit – $205.00Group & High-Risk Classes – $180.00Group Class – $150.00Group Class Military discount – $135.00Group Class with Comfort kit – $175.00Group Military discount + Comfort Kit – $160.00High-Risk Class – $50.00High-Risk Military Discount – $45.00Other Amount

Other Amount

Enter Your Custom Amount In The Box

Total

Payment Method*

Credit Card

Paypal

Credit Card*

Paypal*

PayPal CheckoutCredit Card

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number Expiration Date Security Code   Cardholder Name

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Phone

This field is for validation purposes and should be left unchanged.

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