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Caring for health. Caring for life.

Contact Us for Personal Support

If you would like to speak to someone about your loss, please fill out the form below.  A member of the Affinity BirthPlace staff will contact you.  Thank you for inviting us to help you through this difficult time.

Name*

Phone*

E-mail address*

Your Doctor's Name*

Tell us about your loss

Choose one: MiscarriageStillbirthEarly infant deathOther

How can we help you?

Please call me. Please e-mail me. Other (see below)

If "Other," please explain.

If you would like us to call you, please indicate the best time of day to call.

If we are unable to reach you, can we leave a phone message?

Yes No

If you would prefer to speak with someone directly or more urgently, please call St. Elizabeth Hospital at (920) 738-2487 or Mercy Medical Center at (920) 223-1280.

Send the form

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