Birth Ways
1600 Shattuck Avenue
Suite 122
Berkeley, CA, 94709
510.869.2797

Birth Pool Rental Agreement Form
Thank you for choosing to rent a birth pool from BirthWays!

Please complete this form, and a member of our staff will contact you within the
next few days to confirm your reservation.

Thank you!
 

Parent Information
Yes
No
Not Sure
Yes
No
              
 

Birth Pool Information
PLEASE NOTE: Your payment (minus a $50 non-refundable processing fee) is fully
refundable if you decide to cancel BEFORE we ship your pool. Please see
second page for more details on our cancellation policy.
Spa-N-A-Box Birth Pool Kit (with round-trip shipping in US) $350.00
Spa-N-A-Box Birth Pool Kit (will pick-up in Berkeley, CA) $250.00
Midwife
Doctor
Nurse
Friend
Website
Book
Repeat Client
Other
 

Birth Practitioner Information
Home
Hospital
Birth Center
Other

(XXX) XXX-XXXX
 

Clicking the submit button will send us your registration
and take you to the payment page: