Private Services Registration
Contact Information
Name
*
Birth Partner Name
Estimated Due Date
*
Planned Place of Birth
Address
*
City
,
State
and
ZIP Code
*
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AA
AE
AP
Phone Number
*
Email
*
Additional Requests
Services
Private Services
*
Private One-Day Thoughtful Birth Intensive ($500)
Prenatal Consultations ($200)
Virtual Birth Doula Support ($500)
Total
$0.00
Terms & Agreements
Terms & Agreements
*
In the event of illness on the part of the instructor, a birth, or inclement weather, services may be rescheduled.
By completing this online registration form, you are agreeing to pay the total amount due for the services selected above. Once payment is received, no refunds will be issued and all sales are final.
For questions, please contact Bloom Birth Concierge at (412) 330-1159 or Hello@BloomBirthConcierge.com.
I have read and agree to the terms above.
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