Doula Client Confidentiality Release  (Download this form as a pdf file here)

Confidentiality of medical & personal information obtained during the course of the doula’s work is of the utmost importance. Failure to comply with these confidentiality regulations could result in penalties.

I (please print)______________________ give my permission, for my doula, Sabrina Roberson of Moon Cycle Arts, or her designated backup doula, to take notes about me, including personal information I choose to disclose to her, and information regarding the labor and birth of my child. I understand that my doula may use this information to provide me with a summary for my own personal use.

I will be giving birth at Hospital. My doula needs to be informed of my medical and personal information and, therefore, I hereby request that the medical staff release to my doula any and all medical and personal information pertaining to my progress in labor and any and all health conditions which may affect the birth of my baby.

Signature: __________________________________________ Date:________________________