On-Call Swedish Doula Request

This request form is for providers and nurses only.

Before you submit a request for a subsidized Swedish Doula, please note the following:

• By submitting this request, you are agreeing that you have had a conversation with this client and have confirmed that they would like to have a doula present at their birth.
• Subsidized Doula Services can only be provided to clients who have active Medicaid/Apple Care, please ensure that the client qualifies for subsidized care before submitting this request.
• We cannot guarantee doula availability. Submitting this request will send an email to all Swedish Birth Doulas. If a doula who meets this client’s preferences is available, they will contact you at the number provided.

Please fill in the patient's information below:

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