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2800-136 Sumner Blvd., Raleigh, NC 27616


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THIS FORM IS FOR MIDWIVES ONLY!
Set up your custom kit with us and get a coupon for 10% off your next purchase with us WHEN YOUR FIRST KIT GETS ORDERED! And don't forget, once we've received 5 orders of your birth kit, we send you an additional $30 Gift Certificate!!

If you are a private client of a midwife or planning an unassisted birth and wish to formulate a birth kit of your own choosing, you may use this form as a guide, but use the shopping cart to place your order. THANK YOU!
Please include quantity, sizes and types in the fields provided.

Basic Underpads 23x24":
Basic Underpads 23x36":
Deluxe Underpads 23x36":
Deluxe Underpads 30x36":
Alcohol Prep Pads:
Plastic Sitzbath:
Plastic Backed Sheet:
OB Pads: Choose from (1) Sterile, pkg of 12, no adhesive; (2) Non-sterile without adhesive, pkg of 12; (3) Non-Sterile with Adhesive, pkg of 12; and (4) Non-sterile with wings and adhesive, pkg of 12; and (5) Peach Contour OB pads, 7x13" in pkg of 20 OR as singles; (6) Capri Regular (Minis), (7) Capri Large (Midis), and (8) Capri X-Large (Maxis) in any amount combination. Capris are available in singles or in bags of 28. Please include Type AND Amount:
OB Pad for Heavy Afterbirth with Adhesive, 28" in length:
Sterile Gloves PAIRS: AVAILABLE IN S/M/L SIZES: Medline Latex, Medline Synthetic, Medline Nitrile and Medline Aloetouch. AVAILABLE IN 6, 6.5, 7, 7.5, 8, 8.5: Protegrity/Protexis Latex and Perry Performance Plus Neoprene and Please include Size, Type AND Amount):
Sterile Gloves Single: Choose Latex (S/M/L), Synthetic (S/M/L) & Aloetouch (S/M/L) and Please include Size, Type AND Amount:
Mesh Panty (any amount) and/or Protection Plus Underwear (Depends-style), any amount: Please include Type AND Amount:
Perineal Bottle:
Perineal Packs: Choose (1) Cold w/adhesive; (2) Warm w/adhesive, (3) Cold w/o adhesive and (4) Hourglass Cold w/o adhesive Please include Type AND Amount:
Bulb Syringe (2 or 3 ounce, choose Davol or Economy) Please include Type AND Amount:
Digital Thermometer (Standard - 60 sec or Flexible tip - 9 sec):
Gauze: (1) AMD 12-ply, (2) Medline 8-ply, (3) Medline 12-ply, (4) Tray of 10 - 12 ply, (5) Curity Cellulose Nonwoven Fabric 12-ply, (6) McKesson Non-woven Sponges 4-ply), (7) Avant Gauze Sponges, 6-ply, (8) Kerlix Gauze Roll, (9) Medline Post-op Sponges Please include Type AND Amount:
Straws:
Paper Tape Measure, 36 or 72":
Newborn Hat: Choose Economy or 100% Cotton and indicate number desired Please include Type AND Amount:
With 100% Cotton Hat, clients can choose white, blue or pink.
Povidone Solution (Choose from 4 oz or 8 oz) or PeriClens by Shonda Parker:
Povidone Scrub Brush:
Dyna-hex (Hibiclens) Solution (4 oz. or 16 oz.):
Dyna-hex (Hibiclens) Scrub Brush:
Lubricating Jelly: Medline Brand, choose 3g, 5g, 2 oz, and 4 oz, Surgilube in 3g or 2 oz, Aplicare in 3g packets. Please include Type AND Amount:
Mattress Cover (clients choose from California King, King or Queen):
Cord Clamps, Sterile Cord Tape, Umbi-Rings and Hesseltine Clamps Please include Type AND Amount:
Emesis Basin (Choose Kidney-shaped or 6-Quart):
Fracture Bedpan:
Kleenprint Footprinter:
Homebirth Certificate, clients choose from 8 styles, NEW STYLES TO CHOOSE FROM!:
Afterbirth Sitz. AVAILABLE IN PLASTIC JAR WITH SEALED PACKAGING: Choose from Lucy's Garden Soothing Sitz, 4 oz, 8 oz and 16 oz.; Wishgarden, 3.5 oz. - PACKAGED IN FOLDED BAG: Intimate Solutions (4 or 8 ounce):
Perineal Massage Oil, Wishgarden - 4 oz or Olive Oil in 4 or 8 oz:
Infant Heel Warmer:
Lansinoh Lanolin, 1.41 oz or 0.25 oz:
Birth Pool Liner, specify type (La Bassine, La Bassine MAXI, BPIAB Regular or BPIAB MIni, Oasis Round (Generic, but higher quality than Eco), Oasis Elite, or Eco Generic (Small or Large) for All Pools:
Birth Pool, specify type La Bassine, La Bassine MAXI, BPIAB Regular or BPIAB MIni, Oasis or Oasis Elite :
Shoulder Length Gloves, Regular style OR Band-A-Sleeve:
Waterbirth Net:
Delee Trap (8 or 10 Fr), Available in regular with contro-vac valve or Argyle style Please include Type AND Amount:
Oral Vitamin K for baby - Bio-K-Mulsion:
Amnihook:
Amnicot:
Amnicator:
Infant Lancet, choose from these lancets:
Floating Water Thermometer, Choose Animal Shape or Poolmaster:
25' Hose:
Faucet Adapter:
Sterilization Pouch (Choose from 3.5x9", 5.25x10", 7x13", 8x16", & 12x15") ":
Add the NEW Homebirth Baby Book as an option for clients!:

Please include contact information including name, email address, business address and phone number. Our system sends this email so your email address is never recorded. Without this information, your kit CANNOT be set up! :


Please feel free to embellish or further explain any selections above,
ask any questions you may have, and feel free to look over our
website and add any other items. We'd also like to hear about any
other items that you'd like to see sold on our website.



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