Dr. Jessica's Birth Attendance Services

Dear Parents,

Thank you for considering my services to attend the birth of your child! It is an honor which I cherish, and I would like you to be informed about what you can expect of me at your birth. If you have any questions, concerns, or if I have not addressed in the contract below a need or desire you would like to have at your birth, please feel free to let me know. If you would like references of patients of whom I have had the joy of serving during their birth experiences, I would be happy to supply them at your request.

Thank you,

Dr. Jessica

 Dr. Jessica Allen's Birth Attendance Services Contract

Description of Services: Under her scope of practice and license as a pediatric & pregnancy chiropractor, Dr. Jessica will attend an established patient's birth at their request for the following services:

1) Help to organize a finalized birth plan "A" (Your ideal birth), "B" (Some intervention required), and "C" ("Emergency plan") to serve as a tool during labor & delivery to implement your ideals between your family and your other providers.

2) Like a "day-of-the-big-race" professional, she helps to address physical, emotional, and mental components of your "baby marathon". For the mother, during labor and delivery she uses chiropractic care, myofascial release, and cranio-sacral therapy, based on mother's desires (which may change during different stages of labor and is at her discretion). Whether she prefers deep work into your muscles or gentle energy balanced techniques, Dr. Jessica will cater to your health care needs.

3) For the father, if he is an established patient, Dr. Jessica will treat him as necessary with chiropractic care, myofascial release, and cranio-sacral therapy.

4) For your newborn baby, Dr. Jessica will establish your child as a new patient, perform a complete neonatal physical, neurological, and chiropractic examination. She will perform a chiropractic adjustment, myofascial therapy, cranio-sacral therapy, or other treatments if indicated.

Parent's Duties:

1) Prepare and share your tentative and/or finalized birth plan. Include a telephone list of providers and birth arrangements.

2) Arrange a meeting between the providers and attendees before the birth with Dr. Jessica.

3) Inform Dr. Jessica of who will call her (she will supply her phone number to you) at these times:

          a) Onset of inital, regular (non-Braxton-Hick's) contractions

          b) When you plan to move to the birthing location

          c) When you'd like her to join you there

4) Sign informed consent form: I/We, ________________________, request Dr. Jessica J. Allen to be present at the birth of our child/ren, ________________________, who is/are due to be born on or about __________________. By signing this I realize that she will be responsible only for those duties within her scope of practice as a chiropractor as mentioned above for those persons who I/we have named here: _____________________ ___________________________ _________________________. I/We acknowledge that she will not perform duties associated with the actual delivery of our child, nor will she be responsible for emergency medical care outside of her scope of practice. We realize that her presence will not a substitute for trained birthing support professionals, though she may help with coaching for relaxation and breathing techniques.

Dr. Jessica's fee may be billed to your insurance company for established parent's benefits and newborn's benefits. Anything not covered by your insurance company will be your direct responsibility. Please be aware of your benefits and ask Dr. Jessica if you have any questions. Financial arrangements are also available.

 Signed:________________________________ Date: __________________________

Signed:________________________________ Date: __________________________

Witness:________________________________Date: __________________________