WELCOME!

Welcome to Gifted Hands Midwifery! We are thrilled that you are considering us for your prenatal care and home birth. At Gifted Hands Midwifery, we strive to provide the highest level of compassionate, holistic, evidence-based care while allowing for a collaborative effort between you, Midwife Kay Cleveland, CNM, and the rest of the Gifted Hands Midwifery Team.

Please take a moment to complete the new patient inquiry form below, and then schedule your consultation with us.

The form below collects your contact information as well as some brief GYN history. We know that your online privacy is important, so please review our privacy policy to see how Gifted Hands Midwifery uses and protects your information.

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pregnancy/Birth Number

Any complications with previous pregnancies (if applicable)

Date of Last Missed Period

YYYY

Current obstetrician name and address (if applicable)

Age of first menstrual

Date of your last Pap Smear

YYYY

Pap Smear was:

Type of treatment is pap smear was abnormal (if applicable)

Were you on birth control at the time of conception?

History of Birth Control Use

Surgeries

Please list any surgeries you have had. Write N/A if not applicable.

Hospitalizations

Please list any hospitalizations you have had. Write N/A if not applicable.

Family Health History

Please list any family history of cancer, heart disease or any genetic disorders that you are aware of.

Do you have any medical problems?

Why are you interested in home birth?

Midwifery and home birth care is a partnership. This type of concierge-style maternity care encourages mothers to be active participants in their own care. There is also a higher level of responsibility that is required when planning for a non-medical approach to your maternal health care. Are you willing to accept this level of accountability, suggestions & modifications necessary throughout your care to achieve the goal of a home birth?

Gifted Hands Midwifery

FAQs

New Client Information

Loganville, GA 30052

Phone: 470-504-3856

New Client Inquiry

WELCOME!

Gifted Hands Midwifery

Gifted Hands Midwifery