Thank you for your interest in the Simply Birth program.  Please complete the following application.

Simply Birth Application

General Information
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Have you had a previous un-medicated birth?
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Have you previously applied for and completed the education plan for Simply Birth?
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What is your ethnicity?
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Brief Health History
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You have you any bleeding disorder OR have had a previous pregnancy/delivery with a large amount of blood loss.
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You had a previous C-section, other uterine surgery OR a very difficult vaginal delivery.
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You have had a stroke, blood clots OR any history of high blood pressure.
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You have a history of diabetes, heart disease, lung disease OR kidney disease.
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You have hepatitis, AIDS, tuberculosis, or active herpes.
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You have a mental health condition OR history of substance abuse.
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You have another medical condition not listed.
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You have twins, your baby is breech, your baby is really small (IUGR) OR really large (macrosomia), your placenta is blocking the cervix (placenta previa) OR that there are any genetic conditions with your baby.
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Medications
Are you taking medications for any of the following conditions?
Are you taking any other prescription or non-prescription medications?