To secure your place, please submit this completed form and you will be contacted to arrange payment.
Birthing Mother’s First Name
Birthing Mother’s Last Name
Birthing Companion (e.g. spouse, friend) Full Name
Relationship to Birth Mother (spouse, partner, etc.)
Birthing Assistant Full Name (if applicable)
Relationship to Birth Mother (doula, friend, etc.)
Care Provider Full Name (eg. Midwife/GP/Obstetrician)
Care Provider Title
Care Provider Practice Name and Location
Care Provider Phone Number
Hospital / Birthing Facility Name and Location
When is your baby’s approximate arrival date?
How many weeks pregnant will you be when you begin classes?
Is this your 1st, 2nd, 3rd etc baby?
Where did you hear about Mindful Impact?
Is there any important information, medical conditions, psychological or psychiatric treatment you need me to be aware of before classes commence?
I wish to enrol for the following Hypnobirthing Australia Class:
I will be paying with Direct Deposit or via PayPal (see options below)
Payment Options (1) Direct Deposit Details - Bank Name: Beyond Bank; Account Name: Tania A Davies; BSB: 325 185; Account Number: 03394890 [Include your name as a payment reference] Option (2) Credit Card: Request an invoice for credit card payment. A small processing fee of 2.2% will be added with this payment option.
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