• Date of Birth*
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  • Preferred Appointment Time
  • Preferred Contact Time

  • Medical History

  • Do you have a history of:
  • History of Drug/Alcohol Abuse:*
  • Current Smoker?*
  • Do you have any known allergies?*
  • Are there any complications or problems associated with this pregnancy:*

  • Obstetric and Menstrual History

  • Do you know the date of your last menstrual period?*
  • When was your last menstrual period?*
     - -
  • Did you have an ultrasound(U/S) to confirm this pregnancy?*
  • When was the U/S completed?*
     - -
  • Date of last delivery
     - -
  • What was the due date?
     - -
  • Did you ever have an ectopic or molar pregnancy?*
  • Do you have an IUD in place?*

  • Financial Assistance Screening

  • Are you currently receiving public assistance?
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  • Text Messaging and Opt-Out Policy
    By providing your phone number and opting in to receive text messages from our company, you consent to receive SMS and MMS messages regarding your account, services, promotional offers, or other relevant information. Message frequency may vary.

    Opt-Out:
    You can opt out of receiving text messages from us at any time. To stop receiving messages, simply reply "STOP" to any text message you receive from us. After opting out, you will no longer receive text messages unless you re-enroll by contacting us or providing express consent again.

    Message and Data Rates:
    Standard message and data rates may apply to any text messages sent or received, depending on your mobile carrier's plan.

    Privacy and Patient Information:
    We are committed to protecting your privacy and the confidentiality of your patient information. By opting in, you agree to the use of your information solely for the purpose of communication related to your healthcare and services.

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