I confirm that I have discussed doula services with my patient, named above, including the scope of support (physical, emotional, and informational care during the prenatal, labor, and/or postpartum period).

The patient has expressed interest in receiving doula services and has provided verbal consent for referral to [Doula Organization Name].

The patient understands that:

Doula services are non-medical in nature
Participation is voluntary and may be declined at any time
Relevant information may be shared for the purpose of coordinating care and billing, as permitted