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
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
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Birthday

MonthDayYear
Date of birth
Age
Guardian's Contact Info

First NameLast Name
Guardian's Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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

Other
Primary way to connect to internet for Telehealth Visits.

Other
Referral Source (How did you hear about us?)

Other
Ethnicity or Culture
Race

Other
Are you currently seeking to re-enroll in our Maternal Telehealth Program?
Are you over 13? If you are under 13, please have your guardian update and sign at the bottom
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
Are you taking any medications or supplements?
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:

Other
If you had any other pregnancy complications, please describe them here.
Pregnancy Complications
Do you have a current Healthcare Provider for your pregnancy?
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 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.
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.)
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).
Should be Empty:

Agape's Maternal Virtual-Health Services Enrollment

Pregnancy History

Your insurance may offer additional resources!