• Date of Birth*
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  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • I am inquiring about (choose one)*

  • The women's care concierge program is a 12-month commitment. Dr. Perlow will see you for 4 standard visits and any needed care between.

    Concierge care is HOW we provide our services. Healthcare services are WHAT we provide and billed separetly from the membership fee.

    • The Concierge Membership fee is self-paid; it is not covered by insurance.
    • Healthcare services can be covered by insurance or self-paid.

  • The obstetrical practice for concierge care is a 10-month commitment. Dr. Perlow will see you for the duration of the pregnancy through four months postpartum.

    Concierge care is HOW we provide our services. Healthcare services are WHAT we provide and billed separetly from the membership fee.

    • The Concierge Membership fee is self-paid; it is not covered by insurance.
    • Healthcare services can be covered by insurance or self-paid.
  • Do you understand the Membership Fee for Concierge Practice is separate from any Healthcare Fees and cannot be covered by insurance?*

  • If you are not currently pregnant, you will join as a Women's Care patient. If you become pregnant, at 13 weeks of pregnancy your fees will be increased to the pregnancy membership for 10 months.

  • If you know, enter the first day of your last menstrual cycle below.
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  • Are you Spontaneous Conception?*
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