PROMISE BABY STORIES

I AUTHORIZE PROMISE COMMUNITY HEALTH CENTER TO FULL USE AND DISCLOSURE OF MY AND MY DEPENDENT'S NAMES, PHOTOS, AND INFORMATION ON THE FOLLOWING MARKETING MATERIALS.*

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Promise CHC Website
Promise CHC Social Media
Promise Print Materials

I UNDERSTAND THAT I MAY REFUSE TO SIGN THIS AUTHORIZATION. MY OR MY DEPENDENTS MEDICAL CARE WITH PROMISE CHC WILL NOT BE AFFECTED UPON MY SIGNING OR MY REFUSAL TO SIGN. I UNDERSTAND THAT I MAY REVOKE THIS AUTHORIZATION AT ANY TIME EXCEPT TO THE EXTENT THAT PROMISE CHC ALREADY HAS USED MY PHOTO/VIDEO AND/OR INFORMATION.

PARENTS' FULL NAME*

if you would like to leave your last name off any marketing then please just put first names

PARENT EMAIL*

just one email please

PARENTS' HOMETOWN

BABY FULL NAME (first, middle, last)*

If you would like to leave your last name off any marketing then please just put in first and middle name

BABY GENDER*

MALE
FEMALE

BABY BIRTHDATE

BABY TIME OF BIRTH

:

BABY WEIGHT (lbs and oz)

BABY HEIGHT (in)

LOCATION OF BIRTH*

HOME
HOSPITAL

IF APPLICABLE WHAT HOSPITAL

WHAT PROMISE STAFF ASSISTED WITH PRENATAL APPOINMENTS?*

WHAT PROMISE STAFF ASSISTED WITH LABOR/DELIVERY?*

SIBLINGS (NAME, GENDER AND AGE)

if you would like to leave your last name off any marketing then please just put in first name

WE WOULD LOVE TO HEAR ANY HIGHLIGHTS OR COMMENTS ABOUT YOUR BIRTH STORY. CHOOSE ONE OR MORE OF THE QUESTIONS BELOW TO ANSWER.

WHAT I APPRECIATED MOST ABOUT OUR PRENATAL CHECKUPS & APPOINTMENTS:

WHAT I APPRECIATED THE MOST ABOUT LABOR/DELIVERY & BIRTH EXPERIENCE:

WHAT WOULD YOU TELL OTHER PATIENTS CONSIDERING USING PROMISE FOR THEIR PRENATAL CARE?

WHAT WOULD YOU TELL OTHER PATIENTS CONSIDERING HAVING A HOME BIRTH?

PLEASE UPLOAD ANY IMAGES YOU WOULD LIKE PROMISE TO USE IN ADDITION TO THE ONES TAKEN AT PROMISE

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

If you would like to share high res images or more images than what this upload will allow, please use Facebook messenger to message them to Promise with your name OR email to kgesink@promisechc.org!

If you had a professional photographer at your birth and need/want to tag them in your photos please type in their business name here:

WOULD YOU BE WILLING TO TAKE PART IN A VIDEO TESTIMONIAL?*

yes
no thank you

YOUR SIGNATURE:

CALL PROMISE

EMAIL PROMISE

FIND PROMISE