Agape's Maternal Virtual-Health Services Enrollment

Agape's Maternal Virtual-Health Services Enrollment
VM / TXT
Last Date Contacted

MonthDayYear
Date
AMD Lookup
Re-Enroll

NoYesNew Pregnancy
Call Notes
Outcome / Status
Full Name*

First NameLast Name
Middle Initial
First Letter Only
County*
"Other" If you live outside of these Counties, we will try to find out if there is a program in your area.
Other County
Address*

Street Address

Street Address Line 2

CityState

ZIP
E-mail Address*
example@example.com
Contact Number*
Secondary Phone Number
Please enter a valid phone number.
Birthday*

MonthDayYear
Date of birth
Age
Guardian's Contact Info*

First NameLast Name
Guardian's Contact Phone Number*
Please enter a valid phone number.
Guardian's Relationship*
Guardian's Email
example@example.com
Best times to get a call to schedule appointment. Select your first choice and then select a secondary time also.
Preferred spoken language*

EnglishSpanishCreoleHaitian CreoleDeclinedOther
Primary way to connect to internet for Telehealth Visits.

Phone - iPhonePhone - AndroidTabletDesktop / LaptopLibraryNoneOther
Referral Source (How did you hear about us?)*

Agape Family Dr or StaffW.I.C.Dept. of HealthNE FL Healthy StartMy doctor, outside of AgapeFamily or Friend ReferralGoogleSocial MediaCommunity Event or OutreachFlyerOther
Ethnicity or Culture

Hispanic or LatinxNon-Hispanic or Non-LatinxDecline
Race

Black / African AmericanAsian American / AsianWhite / CaucasianNative Hawaiian / Pacific IslanderNative American / Alaskan NativeMultiracial / BiracialDeclineOther
Are you currently seeking to re-enroll in our Maternal Telehealth Program?

YesNo
Are you over 13? If you are under 13, please have your guardian update and sign at the bottom

YesNo
Date of last menstrual cycle

MonthDayYear
Date
Pregnancy History
Weeks Pregnant
Best guess if you do not know
Estimated Due Date (EDD) or Date of Birth of child within the last 3 Months*

MonthDayYear
Date
Gestational Age
Trimester*

1st2nd3rdPost 1mPost 2mPost 3m4 Month or olderI don't know
Are you taking any medications or supplements?

YesNo
If yes, list any of them below.
Other than normal supplements
Any history or concerns about any of these pregnancy-related complications? Select all that apply:

AnxietyDepressionSubstance Use DisorderAsthma / AnemiaBlood Clots / Pulmonary EmbolismDiabetes / Gestational DiabetesHypertension / Eclampsia / PreeclamsiaObesity / Rapid Weight Gain or LossHemorrhageInfectionAmniotic Fluid EmbolismThrombotic PulmonaryOther EmbolismCerebrovascular AccidentsCardiomyopathyOther Cardiovascular ConditionsNo ConcernsOther
If you had any other pregnancy complications, please describe them here.
Pregnancy Complications
Do you have a current Healthcare Provider for your pregnancy?

Agape Women's HealthYesNo
Current place you go for healthcare
Name of the Office or Practice
Current name of your OB-GYN or Healthcare Provider
If you would like us to invite your Provider to be a Partner with Agape, please provide a number for us to reach out.
Provider's Office Number
Your insurance may offer additional resources!

There are no costs to you for this program! There are no financial eligibility requirements for this program!
Please select your Primary Insurance. If you don't See your Primary Insurance below, Select [Add Option]
Secondary Insurances. Select all other insurances you have.

I don't have anyDeclineHumanaMedicaidSunshine HealthFlorida BlueUnited Health Care
I understand that all my information gathered will be used to determine what programs I am eligible for and to fulfill State requirements. This authorization remains in effect until revoked in writing by me.*

Yes, I understand.No
I authorize Agape Family Health and their Community Partner's to gather information, contact me by all available ways and provide additional services during pregnancy and 3 months postpartum. (Call, Email, Text, Mail, Telehealth, Notifications, etc.)*

Yes, I authorize.No
I am consenting to be included in Agape's Maternal Health Program, a part of the Florida State's Severe Maternal Morbidity Telehealth Program (SMMT).*

Yes, I Consent.No
Should be Empty:

Agape's Maternal Virtual-Health Services Enrollment

Pregnancy History

Your insurance may offer additional resources!