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2DSP Policy Report
Doula's Name (First & Last)
Date of Rejection
*
required
Name of Birthsite
I offered to present and/or presented proof of full immunization
*
Yes
No
Prefer Not to Answer
Doula's Email
Approximate Time of Day
City/Town
Care Provider
*
Required
Obstetrician
Family Doctor
Midwife
Transfer of Care
Anticipated Home Birth?
*
Yes
No
Detailed Description of Events
Submit
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