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Midwife Self Pay Agreement for Clients without Insurance Mobile App

Birthing centers and midwives do not have the ability to give a “quote” before or at the time of the visit. This is because they can’t predict what services may be needed during an appointment. Each procedure code has a price attached to it and we would like our billing team to be able to discount those charges before giving you your final bill. The Midwife Self Pay Agreement for Clients without Insurance mobile app includes a self-payment agreement form for patients paying for their own medical services.

GoCanvas has a collection of apps developed for Midwives and Doulas. They are all Free with your GoCanvas Subscription. Check them out in our Application Store!

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Midwife Self Pay Agreement for Clients without Insurance Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    We are happy to provide ongoing care for our families without insurance coverage.

  • Ico statictext

    Please read, initial each line and sign below.

  • Ico signature

    I understand that my payment today is a down payment on my final bill.

  • Ico signature

    If I have a pap-smear or vaginal culture I will be billed by the lab directly.

  • Ico signature

    If I have other lab work done (blood or urine tests) I may receive another bill from <Insert Name...

  • Ico signature

    If I do not pay my bill in a timely manner, or set up a payment plan, I will lose any courtesy di...

  • Ico signature

    In the event my account goes to an outside collections firm, a $30 fee will be added to my balance.

  • Ico textbox

    Client Name

  • Ico signature


  • Ico date


  • ...and More!

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