| Purchaser |
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| Name |
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| Address |
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| City |
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| State |
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| Zip Code |
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| Country |
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| Phone |
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| Fax |
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| E-Mail |
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Hypnocontrol
Birthing Questions |
(Please complete this form to make individualized
tapes series) |
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| Name you like to be called |
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| Age |
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| Due date or birth |
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| Will you be practicing Lamaze? |
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| Who will be present when you give birth |
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| Will birth be in a hospital or birthing center? |
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| Is this your first pregnancy, please explain
if you had other pregnancies and births |
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| Will a doctor or midwife be present and how
long have you known them |
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| Write down any major fears or any negative
experiences you have about birthing |
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| DO YOU HAVE ANY MEDICAL PROBLEMS |
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| Write down any traumatic experiences you
recently had |
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Form of payment. Check, Money Order, Credit
Card
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| Comments Please include here if you wish
the Aromatherapy program with the hypnosis
series. |
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