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Birth Wellness

Schedule a Consult

Thank you for considering Birth Wellness for your care. Please take a moment to fill out the Consult Form below and we will get back to you as soon as possible. Keep in mind we may be taking care of mothers and babies which can delay our response to you by a few days. We are not in the office on weekends, after hours, or during religious and national holidays.

Name *

First

Last

Email *

Phone Number *

Date of Birth *

Partner's Name

Insurance Status *

Health Insurance
Medicaid
Ministry/Christian Health-share
Not Insured

When was your Last Menstrual Period (LMP) if known? *

The first day of your LMP

What is your estimated due date, if known? *

It's okay of it's not exact, please provide your best estimate.

What pregnancy is this for you? *

1st, 2nd, 3rd...

Share your birth experiences and/or hopes *

If you have had a baby, please let us know what your birth experiences were like and what your hopes are for this baby. If this is your first baby or you are planning to become pregnant, let us know what your hopes are.

Tell us about your diet *

What kinds of foods do you eat every day? Do you consider your diet healthy, with lots of fresh whole foods and high quality protein? Do you regularly eat fast food, sodas, and sugars?

What is your general activity level? *

What kind of activities are you involved in? Do you exercise? Walk? Are you active or sedentary?

Why are you interested in a homebirth or out-of-hospital birth? *

Do you have any health concerns we should be aware of? *

Office Hours

Tue-Thu: 10am-4pm
By appointment only

Contact

Phone: 423-443-4335
Fax: 423-208-9766

Our Location

606 Belvoir Avenue, Chattanooga, TN 37412