Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name *

First Name

Last Name

*

I give Nicky Quick & Company, LLC and its representatives, my expressed permission and consent to take necessary notes relative to information that is pertinent to my labor and birth. This information includes but is not limited to personal information which I choose to disclose relative to the labor and birth of my child, billing and payment information, and other information relative to my association with Nicky Quick & Company, LLC. I understand that this information may be used for the purpose of doula certification / re-certification or for internal business related matters pertaining to my agreement for services with Nicky Quick & Company, LLC. Labor and birth related data collected for purposes of certifications will be shared with the certifying agency with the utmost emphasis on your privacy and only that information required for certification will be shared. By signing this document, I realize that the aforementioned information will be shared with the back-up doula assigned to my birth.

Date *

MM

DD

YYYY

Contract Agreement *

I agree that I have read this client confidentiality release and agree to comply with all policies and information included. I agree to sign this document via electronic signature and that by signing electronically, it serves as my actual hand-written signature on a legal document.