WishList - Pacify

This Birth Wish List is a way for me to ask questions and learn about my pregnancy and giving birth. It helps me be part of decision making during the birth of my baby. I will talk about what I may need with my Pacify Birth Doula. I will share this Birth Wish List with my doctor or midwife during my prenatal visits and talk with them about my wishes. I will bring it to the place where I give birth so I can share it with the people who will be helping me. I understand that a lot can happen during the birth of my baby. My Birth Wish List may change in some ways to keep me and the baby safe.

My Due Date(Required)

My doctor or midwife's name(Required)

Email(Required)

After I complete this form, a copy of my answers will be emailed to the address above:

Questions/Notes:

I am planning to give birth at:(Required)

*If home birth, please call your health plan to talk about it

This is how I am going to get to and from my birth:(Required)

Questions/Notes:

I would like to have a Birth Partner---a loved one or friend for support when I give birth.

Birth Partner Name:

Birth Partner Phone Number:

Questions/Notes:

Questions/Notes or other ideas:

If you selected other, please specify:

When I bring the baby home, what do I think I need?

For example: breastfeeding help, child-care, transportation to follow-up appointments, food. Please use your Pacify app to call your health plan directly if you are concerned about food.