Create Your Birth Plan – Jamestown Regional Medical Center

Name *

First

Last

Physician *

Baby's Physician *

Phone *

Email *

Expected Due Date *

Classes You Have Taken

Select all that apply

Labor Support Person *

First

Last

Relation to You *

Cesarean Support Person (if different than Labor)

First

Last

In the case of a non-emergent cesarean section only one support person is allowed.

Allowed During Labor *

Allowed, if Other *

Pain Relief Methods You Prefer *

Select all that apply

Please Explain Other Pain Relief *

Preferences During Labor *

Select all that apply. Add other preferences in the comments.

Other Labor Preferences

Any special cultural/spiritual traditions you wish to observe?

Baby *

For a boy, will you have him circumcised? *

Feeding Plan *

Select all that appply

Would you like a pacifier for your baby? *

Visitors & Phone Calls *

Other Comments