GCP: Prenatal Intake Form

GCP: Prenatal Intake Form

We are honored that you chose Dr. Allie to care for your new baby! Thank you for filling out this form to help ensure we are prepared for the delivery!
Today’s Date:*

MonthDayYear
Date
Birthing Parent:*

First NameMiddle NameLast NameSuffix
Birthing Parent DOB:*

MonthDayYear
Date
Support Parent/Caregiver:

First NameMiddle NameLast NameSuffix
Support Parent/Caregiver DOB:

MonthDayYear
Date
Due Date:*

MonthDayYear
Date
Primary OB/Midwife:*
Planned Delivery Hospital:*

Hillcrest HospitalUH MacDonald Women’s HospitalOther
Plans for Induction or C-section? Please include timing and any specific indications, if known.
Please include reasons for induction or c-section, if known
Other Birth Plan Information:
Please share anything else you would like us to know about your birth plan
Pregnancy Complications:*

Gestational DiabetesGestational HypertensionPre-EclampsiaIUGRBreech positioning (even if resolved)None of the aboveOther
Please share additional details of conditions listed above, or other pregnancy complications:
Birthing Parent Medical History:*

InfertilityPCOSPrior Breast Surgery/AugmentationDiabetesDepression, Anxiety or Postpartum DepressionThyroid disordersNone of the aboveOther
Additional Birthing Parent Medical History:
Please include any additional medical history that would be useful for us to know
Medications Taken During Pregnancy:*
Any Concerns from OB Regarding Fetus?*
Please include any findings from prenatal ultrasound or other testing
Any Family History (including parents, siblings, grandparents, cousins) of the following:*

Childhood heart conditionsHip dysplasiaGenetic conditionsJaundice (in siblings)Childhood hearing lossNone of the above
Support Parent Medical History:
Please include additional details regarding Family History:
After Delivery:
Feeding Goals:*
Ex: formula feeding, exclusive nursing, exclusive pumping, not sure, etc.
Prior Pregnancy, Birth or Infant Feeding Experience:
Please share any additional history that may be useful for us to know
Infants typically receive Vitamin K, Erythromycin eye ointment, and Hepatitis B vaccination following delivery. Please share below if you are planning to forego any of these treatments, or if you have any concerns you would like to discuss.
Preferences regarding Vitamin K, Erythromycin, or Hepatitis B vaccination:*
If no concerns regarding the above treatments, please write “n/a”
Names/Ages of Siblings and Other Household Members:
Other Support During Postnatal Period:
Birthing Parent Occupation:*
Support Parent/Caregiver Occupation:
Expected Maternity/Paternity / Parental Leave for Parents:*
Is there anything else you would like us to know?
Insurance Information:

While Greater Cleveland Pediatrics does not bill insurance directly, your insurance information may be needed for vaccinations, laboratory studies, or other studies.
Insurance Provider: (ie Anthem, United Healthcare, etc.)*
Please type the name of your Insurance Provider
Member ID:*
Member ID / Policy Number
Group ID:*
Group ID Number
Primary Insurance Holder Name*
This is typically the parent who is the primary policy holder
Primary Insurance Holder DOB:*

MonthDayYear
Date
Additional Insurance Information:
Please include any additional information, if needed
Please upload a photo of your Insurance Card, FRONT:

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Insurance Card: FRONT Cancelof
Please upload a photo of your Insurance Card, BACK:

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Insurance Card: BACK Cancelof
If you are unable to upload a photo of your insurance card, please email directly to ADMIN@clepeds.com. Thank you!
Thank you for completing this information! Please reach out with any questions. I am excited to care for your family!

Thank you,

Dr. Allie Effron

Greater Cleveland Pediatrics
Should be Empty:

GCP: Prenatal Intake Form

After Delivery:

Insurance Information: