Birth Mother's Name
_____________________________ Phone
# ______________
Hospital
_______________________________________ Phone
# ______________
Adoptive Family
_________________________________ Phone
# ______________
Doctor's Name
__________________________________ Phone
# ______________
Adoption Professional
____________________________ Phone #
______________
______ To see the baby ______
Not to see the baby
______ To be in a private room ______ To be in a
non-maternity ward
______ To know the sex of the baby ______ Not to know the sex
of the baby ______ To hold and feed the baby ______
Not to hold or feed the baby
______ Bottle Feed (Formula) ______ Birth
Mother Breast Feed ______ Bottle Feed (Soy Formula)
Special Instructions:
_____________________________________________________
____________________________________________________________________________________________________________________________________________
Please allow the following to see the
baby:____________________________________
____________________________________________________________________________________________________________________________________________
Please allow the following to hold the
baby: ___________________________________
____________________________________________________________________________________________________________________________________________
Please place a “no information/no
publicity”, except for the following: _______________
____________________________________________________________________________________________________________________________________________
Please allow the following to be in the
delivery room during the birth: _______________
____________________________________________________________________________________________________________________________________________
Additional special arrangements made
for the adoptive parents:___________________
____________________________________________________________________________________________________________________________________________
Circumcision if male: Yes ______ No
______ Please consult adoptive
parents: ______
If
possible I would like _______________________ to be able to cut the umbilical
cord.
Birth Certificate:
______ Allow me to enter the name
______Fill out
(you specify) _____________________________________________________________
______ Fill
out “Baby Boy” or “Baby Girl” with ______________________ as a surname
______ Enter my last name, and the
adoptive parent(s) choice of first and middle name
______ Other:
__________________________________________________________
Discharge from hospital:
______I
wish to leave with the baby and meet the adoptive family after we are discharged from the hospital.
______I wish to leave before the
baby and the adoptive parents leave the hospital.
______I wish to leave after the
baby and the adoptive parents leave the hospital.
______I
wish to leave at the same time as the baby and the adoptive parents leave
the hospital.
Misc:
_______Yes, I want to order my
own set of newborn pictures. ______ No
_______Yes I want to have the
baby's cap. ______
No
_______Yes I want to have the
baby's bracelet. ______
No
Additional requests and comments: _________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________ ___________________
Birth Mother
Signature Date
___________________________________ ___________________
Witness Signature Date