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Pain Management Agreement
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Please complete the form below:
This agreement is to clarify my desire for pain management and how I would like my support team to respond during labor
Client Information
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
The Agreement
My preference for labor is
*
A natural drug free labor
To have medication when I decide I am ready
To only have narcotic (IV) medication in labor
To have an epidural and I do not want narcotic medication
To have either narcotic medication and/or an epidural depending on the situation and my needs at the time
I would like my support team to:
*
Not offer any pain medication. If I decide to have medication I will ask for it.
Offer medication. I want to be told when I can have medication so that I can have it as soon as possible.
If I ask for an epidural or other pain medication, I want my support team to:
*
Encourage me to keep going no matter what I say. Talk me out of it! Help me get past this difficult point in my labor
Talk me out of it, unless I use the code word specified below
Ask me to try the number the number of contractions specified below and then, if I still want it, I will ask again
Ask me to wait for more minutes and then if I still want it, I will ask again
Remind me to try and wait until my cervix is the amount of cm dilated specified below
Assist me in getting an epidural when my cervix is the amount of cm dilated specified below
Assist me in getting an epidural as soon as I ask for it
Assist me in getting an epidural as soon as I am able to
Other
If your above selection requires specifications, please outline below:
i.e. code word, number of contractions, number of cm dilated, etc.
Client Signature
Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Contract Agreement
*
I agree that I have read this accurately outlined my desire for pain management and how I would like my support team to respond during labor. 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.
Client Electronic Signature
*
Partner's Name
First Name
Last Name
Contract Agreement
I agree that I have read this pain management agreement and agree to comply with all 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.
Partner Electronic Signature
Thank you!
