Full Name
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Include middle initial
First Name
Last Name
Birth Date
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DD
YYYY
Partner's Name
First Name
Last Name
Phone
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(###)
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Address
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Please provide the same address listed on your insurance
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Estimated Due Date
MM
DD
YYYY
Approximate date of last menstrual period
If you're really not sure, add three months to your due date, then subtract one from the year. If I'm due June 26th 2035, my last period should have been September 26th 2034.
MM
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YYYY
Are you insured by Oregon Health Plan?
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Authorization to bill OHP
By typing your name below, you authorize North Star Doula Service to bill Oregon Health Plan for doula services rendered in your benefit.
First Name
Last Name
Service Agreement
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By typing your name below, you agree to the terms of service as follows:
SCOPE:
Doulas provided by North Star Doula Service have all successfully completedan accredited Doula Certification Course and either hold or are in the active process of
undergoing current certification with a major Doula Certification Institution, such as DONA, PALS, or NAPS.
Additionally, any affiliated doulas may hold varying degrees of education, training, expertise, or certification which lend beneficial experience from which to draw in your service. This education, including but not limited to: aromatherapy certification, massage therapy certification, RN, LM, CPM, CNM, or MD licensure is not considered in scope of doula service and as such will not be included on the final invoice and will not be billed separately unless expressly agreed upon, in writing, before administration of such services.
AGREEMENT
I have hired a doula through North Star Doula Service and agree to receive the following services:
* Two in-home prenatal visits, lasting approximately 60-90 minutes, provided to prepare me and my partner for childbirth.
* 24-hour email, text, and phone support throughout the course of the contract, providing reasonable turnaround time if doula is not immediately available. For example, if doula is asleep and the request is non-urgent, you may receive a response the next day.
* 24 hour on-call availability the week before, the week of, and the week after the estimated due date. Every effort will be made to attend a delivery outside of these dates.
* Constant support during labor and delivery for a term of 24 hours which may be extended, for no additional cost, at the discretion of the attending doula, or transferred
after that point to the agreed-upon backup doula until the birth is complete and immediate postpartum support has been provided as detailed below.
* Immediate postpartum support until: the first successful breastfeeding has been initiated, express verbal release is given by the client, both the client and doula agree that no further care is needed immediately, or care has been successfully transferred to the backup doula in the event that the primary doula is unable to continue providing support.
* In-home postpartum visits, lasting approximately 60-90 minutes, provided to support the adjustment to parenthood, breastfeeding, physical and mood fluctuations, and the processing of the birth experience.
PRIVATE PAY/PRIVATELY INSURED
If I am privately insured, I agree to pay my doula in full (via check payable to North Star Doula Service, LLC) on or before the date of the last prenatal in-home visit prior to my birth. In the event that my birth is not attended by either my primary or backup doula, and I have made reasonable effort to make contact via at least two phone calls with voice mails left expressing my need to have service, 75 percent of the fee will be refunded and I will be released from the remainder of my contract to receive postpartum support, unless I choose to receive it, in which case I will be refunded 50 percent of the fee.
If my birth takes place before or after the on-call period, every effort will be made to attend the delivery. In circumstances wherein reasonable efforts have still been made to contact the doula, but the birth is unattended by the primary or backup doula, 50 percent of the fee will be refunded and the remainder of the contract will remain intact.
If I have not made reasonable effort to contact my hired doula (two phone calls with two voice mails) and, as a consequence, did not receive the agreed upon labor support, no refund will be provided. Postpartum services will still be offered and may be increased in number or length, at the sole discretion of the doula.
Though our doulas hold an unimpeachable record of highly satisfied clients, if a situation arises in which doula support is deemed in breach of this contract, unsatisfactory, or harmful, every effort will be made to resolve the concern, on a case-by-case basis, up to a full or partial refund at the discretion of North Star Doula Service, LLC.
I understand that I may request an invoice to submit to my insurance company for reimbursement. Doula services may be paid for using an FSA or HSA account.
If I am insured by Oregon Health Plan, I agree to make reasonable contact (two phone calls and two voicemails) with my doula at the time of labor. No funds may be collected by the doula for services rendered. All other, non-financial aspects of the Service Agreement remain in effect.
First Name
Last Name
Informational Release
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By typing your name below, you agree to the informational release as follows:
I grant permission for my doula to discuss with myself, my birth partner, my backup doula, and my obstetric providers (OB, CNM, RN) specific healthcare details which may be pertinent to the improvement of my care. Details which may be shared are still protected by the Health Insurance Portability and Protection Act and will be kept in strict confidence between the aforementioned individuals.
First Name
Last Name
Photographic Release
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I grant permission for North Star Doula Service, LLC to publicly display, either in digital or print form, images and/or their descriptions from my birth with the following restrictions (please check one):
