Pregnant Person's Name *

First Name

Last Name

Partner/Support Person's Name *

First Name

Last Name

I/we the client(s) agree to the following (check all that apply):

I would like photos to be taken

I would like video to be taken

No photos or videos (if checked, please skip to signature)

I would like photo/video to be taken:

During Labor

During Birth

Immediately After Birth

During Postpartum Visit(s)

The following cameras/devices may be used by Doula to take photo/video:

Client's Camera/Phone

Partner's Camera/Phone

Doula's Camera/Phone

Preferences surrounding candid photos:

I would like candid photos

No candid photos; explicit permission must be given first

Preferences surrounding intimate or graphic photos:

(This can include photo/video that show: baby being born, any natural body fluids in frame, breastfeeding, breasts/nipple, or any other images that are intimate in any way. Some people like to have these images captured, and other's don't! It's entirely up to you:)

No graphic or intimate photos please

Graphic and/or intimate photos are allowed when taken with tasteful consideration

Please check to indicate your understanding of the following: *

I/we understand that policies at my birthing facility may forbid video or photos to be taken at certain times. I understand that it is my responsibility to negotiate the photo/video policy with staff, not my Doula’s.

I/we understand that taking photo/video are not my Doula’s main focus; that she is not a professional photographer, and no guarantee of any specific photo/video can be made.

I/we understand that the Doula agrees to always use professional discretion when taking photos/videos. The Doula agrees to share every photo/video taken with client(s), and will never share with others without explicit permission to do so. The doula will not keep any photos/videos taken on her own device(s) without explicit permission to do so.

Please check to indicate whether permission is given for the following:

(You may leave any unchecked that you do not agree to).

I/we give permission to my Doula to use photos of me and my baby in printed materials. (Each photo will be subject to client’s approval, and client permission may be revoked at any time)

I/we give permission to my Doula to use photos of me and my baby on her website or online social media. (Each photo will be subject to client’s approval, and client permission may be revoked at any time)