Client Confidentiality 

 
 

Printable Version

 

I, __________________________________& __________________________________(printed names)

at _________________________ ______________________(address),___________________ (phone #), give my permission for my doula, Lea Garner to take notes about me, including personal information I choose to disclose to her, and information regarding my labor, birth and postpartum, as well as any information regarding my child/ren. I understand that this information may be used for the purpose of doula certification or recertification and may be shared with the Certification Committee of DONA International. I realize that this information will be shared with the doula that is providing backup support. I also understand that my doula may use this information to provide me with a summary for my own personal use.

                    

Signature: _______________________________________ Date: ________________ 

                

 

Signature: _______________________________________ Date: ________________ 



 

I, Lea Garner, as a certified DONA Birth Doula I am held to DONA’s Code of Ethics and will adhere to strict confidentiality with any and all information that is shared. Your personal details, experience, and/or photographs will never be shared without further explicit permissions. 

 

Signature: _______________________________________ Date: ________________ 

  Lea Garner, CD(DONA), HCHI

 

Signature: _______________________________________ Date: ________________

 

OBS 07/2016