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With Women, LLC
P.O. Box 325
Arvada, CO 80001

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Your name:
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Phone number:
Estimated due date:
What number baby is this for you?:
Is this a singleton or multiples pregnancy?
Do you have other children?:
Where will you be giving birth?:
Who is your care provider?:
In what part of town do you live in?:

What can we do for you? (Check as many as needed.)

Please contact me about...

I would like more information about hiring a monitrice.
I would like more information about childbirth education.

If you would like more information about hiring a monitrice, please fill out what pertains to you below.

Why are you seeking the care of a monitrice? What aspects of monitrice care are of interest to you?

Are there any special circumstances that may be important to consider?  For example, is this a vaginal birth after a cesarean,
are you a single parent, or is there any special medical consideration for which a monitrice with specific experience might be helpful?

Anything else you would like to share?

How did you find out about With Women?

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