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    ★ Receptionist Name (If Assisted with Purchase): ɖʀ. ѕαѕѕιι ℓαηє (sassiilane)  

    ★ Date Package Purchased: 

    ★ Our Packages offer range of weeks.   

        Please specify the exact number of weeks that you would like to  

        give birth in (within the selected range):  

       

    ★   Mom's FULL (including legacy) Name: 

    ★   Mom's Pronoun: 

    ★   Partner's Name:   

    ★   Partner's Pronoun:

    ★   # of Weeks Purchased:    

    ★   # of Babies in the pregnancy:  

    ★   Home birth or Live Avi ?: 

  

    ★   Is the Patient already pregnant?  

    ★   If yes, what is the anticipated / requested due date?   

    ★   Do you have a sex preference for your baby/babies?      

    ★   Do you have a Doctor/midwife In Mind?: ɖʀ. ѕαѕѕιι ℓαηє  

  

    ★   Does the Patient utilize a "Mommy HUD" (If yes, which)? 

    ★   Does the Patient prefer to type or voice?

    ★   Can the Patient hear local chat?    

    ★   If the patient does not speak English, which language do they speak?  

  

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::::::::::::::::::::::::EXAM PREFERENCE::::::::::::::::::::::  

  

    ★   Exam Preference Times / Hours:  

    ★   Exam Preference Days:  

   

Please be advised that patients MAY or MAY NOT receive their time/day preference according to availability. In order to help you with that, we have now created an Availability calendar that gives you a general idea. Be assured that every effort will be made to accommodate your needs. Thank you!   

   

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Please put this notecard in the white drop box and a Midwife with reach out in 3-5 business days not including Sunday. If you dont put it in the White drop box we will not know if/when you bought your package. 

★   Mom's FULL (including legacy) Name: 

★   Partner's Name:  

★   Mom's RL Time Zone?: 

★   Partner RL Time Zone?: 

  

★   Is it okay to contact you Partner with clinic things only?: 

★   If not who are we able to contact?(Need to be different form mom): 

  

★   If there is no contact alternate may the clinic Lawyer Contact your Partner?: 

  

★   Roleplay expectation? (Ex: voice ,text , Para RP, Or just the info): 

  

★    Do you have any Allergies?:  

  

★    Is the gender you have in places is the right one?:  

  

★    Do you want want to know gender at the ultrasound or Delivery?:  

  

★     Do you consent to putting your Baby(s) Birth certificate in the picture gallery in the lobby until such time it is rotated out?:  

  

★     Do you consent for us to take pictures during your Exam/ultrasound for our Social media pages?:  

  

★    Is your due date ok with you?: 

  

All Content © Copyright 2022 Of Little Kisses Maternity Clinic Any attempt to resell or redistribute will result in immediate DMCA report and legal action. 

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