Sample Birth Plan Template

If we have a boy, a circumcision should:
Be performed
Not be performed
Be performed later
Be performed with anesthesia
Be performed in the presence of me
AND/OR my partner
I would like baby’s medical exam & procedures:
Given in my presence
Given only after we’ve bonded
Given in my partner’s presence
To include a heel stick for screening tests
beyond the PKU
To include a hearing screening test
To include a hepatitis B vaccine
Please don’t give baby:
Vitamin K
Antibiotic eye treatment
Sugar water
Formula
A pacifier
I’d like baby to stay in my room:
All the time
During the day
Only when I’m awake
Only for feeding
Only when I request
I’d like my partner:
To have unlimited visiting
To sleep in my room
I’d like baby’s first bath given:
In my presence
In my partner’s presence
By me
By my partner
I’d like to feed baby:
Only with breastmilk
Only with formula
On demand
On schedule
With the help of a lactation specialist
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Sample Birth Plan Template PDF

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