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Home
About
Book
Education
Contact
Name
*
First Name
Last Name
Address
*
Contact Phone Number
*
(###)
###
####
Email
*
Baby's Gender
*
Male
Female
Baby's Name
*
Mother's Date of Birth
*
MM
DD
YYYY
Baby's Date of Birth
*
MM
DD
YYYY
Birthing Experience (This Baby)
Length of Labour (Total)
Length of Labour (First Stage)
Length of Labour (Second Stage)
Labour Started
Self Started
Induced
Accelerated
Nature of Delivery
Vaginal
Ventouse
Forceps
Caesarean
Delivery Environment
Hospital
Home
Other
Name of Midwifery Team
(providing ante/post-natal care)
Names and Ages of Older Children
Drugs Administered During Labour
Gas and Air
Pethadine
Epidural
Other
Other
Any Damage Suffered to Perineum
No
Yes
Any Stitches Required Following Tearing/Episiotomy
No
Yes
Any Post-partum Haemorrhage?
No
Yes
Was Baby
Full Term
Premature
Overdue
At what stage was the umbilical cord cut?
Baby's Weight at Birth
Any current health concerns for baby?
Post-natal Conditions
Have you experienced any of the following since baby's birth?
Sacro iliac pain
Back pains
Stiff neck/shoulders
Sciatica
High blood pressure
Anaemia
Prolonged bleeding
Piles
Mastitis
Depression
Anxiety
How did you hear about the classes
Terms and Conditions
*
Please Read the following disclaimer and tick to the box to agree. * I have read the safety guidelines and policies below and will ensure that I adhere to them. * I take full responsibility for myself and my baby, and for everything that happens to me and my baby in relation to the class. * If I have any concerns, I will seek the advice of my medical professional before proceeding with the classes. * I will keep the Instructor informed of any health issues that arise over the course of the classes, both for me and my baby.
I agree to the terms and conditions
General Data Protection Regulation (GDPR)
*
Please review the statement below and check the box to agree to have your data process in this manner. Customer Data is processed in the following ways: Customer information that is provided will be stored for a period of 5 years. Only yours and your baby’s names are printed for the weekly registers and other relevant documents, the rest of your details are never printed out. Customer information that is held electronically is done so upon a secure storage with password protected access. Customers may be contacted via email or text message with details of the future classes. Please inform Toni-Marie if you do not want to be contacted in the future. Customer data will never be shared with any third party for marketing purposes. Customers can request copies of the data Toni Marie Yoga holds about them at any time. Customers may withdraw consent in the future regarding the way in which their data is stored and used.
I agree to the terms and conditions regarding data handling
Thank you!
