Choose your Legacy doula

*First Name *Last Name *Birthdate Pronouns *Phone number Email Address *Estimated Due Date What number baby is this for you? *Which clinic or provider group are you receiving prenatal care at? * Which Legacy hospital are you planning to birth at? *What specific type of OHP/Medicaid or other coverage do you have? Look on your insurance card if you aren’t sure. Language needs Would you like to be culturally matched with your doula, if available? How do you racially/ethnically identify? Do you need a LGBTQIA2S+ allied doula? Yes No Any other information about yourself, your pregnancy or your support needs that you’d like to share? Would you like to interview two doulas to find the best personality fit or would you prefer to just be assigned a doula? I would like to interview two doulas, if available I would prefer to have a doula assigned to me Privacy Notice
Your privacy is important to us. We are committed to protecting your personal information in accordance with HIPAA and CMS guidelines.

Information Collection and Use
We collect personal information such as your name, contact details, and health insurance claim number to address your questions or complaints effectively. This information will be used solely for the purpose of resolving your inquiries and improving our services.

Data Security
All information submitted through this form is encrypted and stored securely. Access to your data is restricted to authorized personnel only. We implement strict security measures to protect your information from unauthorized access, alteration, or disclosure.

Your Rights
You have the right to access and ensure correction of your personal information. If you have any concerns about how your data is being handled, please contact us.

Potential Risks
While we take extensive measures to protect your information, there are inherent risks associated with online data transmission. Despite our best efforts, we cannot guarantee absolute security. By submitting this form, you acknowledge and accept these risks.

Consent
By submitting this form, you consent to the collection and use of your information as described in this notice. You also acknowledge that you have read and understood our privacy practices.