Name *

First Name

Last Name

Phone

(###)

###

####

Partner's Name

First Name

Last Name

Partner's Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pool Size Requested

Regular

Mini

Target “Birth Pool Kit” Delivery Date

MM

DD

YYYY

Estimated Due Date

MM

DD

YYYY

Caregiver Name

First Name

Last Name

Caregiver Phone

(###)

###

####

Do you have a history of birthing prior to your estimated due date?

Yes

No

Rental Description & Price

Birth Pool in a Box (Including 1 disposable liner) - $210

Non-Refundable Deposit (Due at time of reservation) - $50

ClearFit Heat Cover (Optional) - $35

Set-Up Fee (Optional - only at time of pool delivery) - $25

Delivery Fee - Delivery and/or Pickup each way - $15 (for outside Edmonton region)