Testimonial Form

If you were pleased with your care with us, please take a moment to write a brief testimonial. These are extremely helpful when other families are looking into midwifery care. If you would like to include a photo for the slide show, please send it either via Facebook, E-mail or snail mail.

* Indicates required field

1. Name *

First

Last

2. City/State *

What care or services did you receive from Wiyama Midwifery? *

4. When did you receive care or services from Wiyama Midwifery?

Month *

Year *

5. How was your experience with Wiyama Midwifery? *

6. How was your exerience with the apprentices and students of Wiyama Midwifery? *

7. Is there anything you would have changed about the care or services you received from Wiyama Midwifery? *

8. Would it be ok to share your feedback with the apprentices and students of Wiyama Midwifery? *

YES NO

I hereby give my permission for this testimonial and/or any photographs of myself and/or my child to be used by Wiyama Midwifery in whatever capacity, personal or public, necessary. I admit that I am the owner of the photographs and have shared them of my own volition. *

YES NO

Submit