This page contains various resources and forms specifically designed for the use of my clients.
Forms or Information You Can Download or Print
Client Registration for Insurance Benefits
If you have private health insurance be sure and download this form and give your insurance company a call so that benefits can be verified as quickly as possible
Request For In-Network Exception
Many insurance companies are able to grant in-network exceptions or “network gaps” on the basis of network insufficiency. If so, this means they will pay me at the in-network rate and not the out-of network rate. This also means your deductible and co-insurance amounts are (typically) lower. They will only authorize this if they can see that there are no contracted home birth/birth center birth providers in your area (which is often the case).
Medical and Obstetrical History
This form will need to be be filled out. You can either fill out a copy when you come for your first prenatal visit or print it and fill it out at home and bring it to your first prenatal visit, allowing us more time to talk instead of completing paper work!
MANA Statistics Project Consent Form
I participate in the Midwives Alliance of North America's statistics project. This important project helps to document the safety and value of midwifery care in North America. This type of statistics gathering helps protect your rights to midwifery care. Participation is voluntary. More information about the project is on the form.
I ask all clients to fill this out as early in your pregnancy as possible. There may be other times when I will want you to repeat the survey, and some moms find it helpful to keep track of what they are eating each day periodically throughout pregnancy.
Weekly Diet Checklist
A helpful chart to keep track of daily intake from the basic food groups.
I recommend Homefirst Prenatal Multi-Vitamin with Probiotics for all my clients. You can order them on-line at the Homefirst On-line Store.
VBAC Informed Choice
If you are requesting a vaginal birth after Cesarean you will need obtain a copy of the surgical report from the hospital where your surgery took place, or from your obstetrician. You will also need to read and sign this form.
Group Beta Strep Testing - Informed Choice
Why or why not to test, risks and benefits, treatment options if positive.
Vitamin K For Your Baby - Informed Choice
Information on the benefits and risks of prophylactic vitamin K to prevent bleeding disorders of the newborn.
Prenatal Genetic Screening
An aid to help you determine if you need or might want to have genetic screening tests done during your pregnancy.
Request For Medical Records
Used to request your medical records from other health care providers. You have the legal right to copies of all medical records. Providers have 30 days to comply with your request.
Fetal Movement Count Chart
A simple non-invasive and accepted method of evaluating fetal wellbeing. Not used routinely. An example of when I may ask that this be kept is if you go past your due date.
EMS - 911
This form is for parents having a home birth. I want this form completed and posted near a telephone or very visible area of your home. On the refrigerator is a common place. This should be done by your 36th week of pregnancy.
Preparing for a Home Birth/Water Birth
Guide and instructions, including the supplies you will need to have
Setting Up for A Water Birth
Special instructions for parents who are planning a waterbirth.
Birth Kit Order Form
For you can download and complete to order my custom birth kit from
In His Hands birthing supply company
To order my custom birth kit on-line
What To Do When You Go Into Labor
Just in case you forget or loose the information I give you!
Postpartum Instructions for Mother
Postnatal Instructions for Baby
These are copies of the verbal and written instructions I will give you for your care following birth. These are posted here so you can review them in advance if you like, and just in case you misplace your instructions following birth.
© Copyright 2007 Midwifery Services of South Texas
Permission to reprint pregnancy and childbirth information contained within this website with attribution
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