Classes & Events Registration

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By registering for this event, you agree to receive email confirmation and event reminders. Registration emails may contain confidential information. If you want to receive messages through our secure system, please uncheck this box and you will be asked to create an account and take extra steps to view these emails.

Personal Information

First Name *

Last Name *

Email *

Phone *

Address *

Address 2

City *

State *

Zip *

Billing information is same as personal

Billing Information

First Name

Last Name

Phone

Address

Address 2

City

State

Zip

Simply Birth Program Application

Please complete the following Simply Birth Program application in order to register for the Simply Birth class.

About You and Your Pregnancy

What is your date of birth? *

What is your baby’s due date? *

How tall are you? *

What was your pre-pregnancy weight? *

Who is your doctor or midwife? *

Have you taken any prenatal education classes with this pregnancy or prior pregnancies? *

If yes, list what class and when you took them:

Have you previously applied for and completed the education plan for Simply Birth? *

What number baby is this for you?

Which Intermountain hospital do you plan to deliver at? *

Have you chosen a doctor/provider for your newborn baby? *

If yes, what is the name of the doctor/provider?

Are you being seen by a high risk pregnancy doctor?

Please check all that apply:

Having Twins

Baby is breach

Baby is really small IUGR

Baby is really large macrosomnia

Placenta is blocking the crevix placenta previa

Any genetic conditions with your baby

If you need an interpreter, please specify a language

Si necesita un intérprete, especifique un idioma.

Brief Health History

Have you had a previous un-medicated birth (no pain medicine during labor or birth)?

Have you had a previous C-section, other uterine surgery, OR a very difficult vaginal delivery?

If yes, please explain

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Have you had a successful vaginal delivery after having a C-section?

If marked no, you are not eligible for the Simply birth class but please talk to your provider about other options available to you.

Are you taking medications for any of the following conditions?

Please check all that apply:

Bipolar/Schizophrenia

Depression/Anxiety

Seizures/Epilepsy

Tyroid Disorders

Asthma

High blood pressure

Blood abnormalities

Heart Disease

Please list all the names of prescription, non-prescription medications, or supplements you are currently taking:

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Have you ever been diagnosed with, or had any of the following? Please check all that apply:

Bleeding Disorder

If checked, explain

Previous pregnancy/delivery with a large amount of blood loss

Heart condition, arrhythmias, stroke, blood clots OR any history of high blood pressure or pre-eclampsia

If checked, name which condition(s) you have:

History of diabetes, gestational diabetes, heart disease, lung disease OR kidney disease

If checked, list which condition(s) you have:

Currently have gestational diabetes

If checked, how are you controlling your gestational diabetes?

Hepatitis, AIDS, tuberculosis, or active herpes

If checked, you are not eligible for the Simply Birth class but please talk to your provider about other options available to you.

Please list any other medical conditions not listed above:

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Email Preferences

Personal Information

Billing Information

Simply Birth Program Application

About You and Your Pregnancy

Brief Health History

Are you taking medications for any of the following conditions?

Have you ever been diagnosed with, or had any of the following? Please check all that apply: