New Client Information Form
Thank you for your interest in NorthPointe Birth Center. Please complete this form and a birth center staff member will be in touch as soon as possible.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Your Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What type of care are you interested in?
Pregnancy and Birth Care
Well-Body Care
Preconception Care
Other
Estimated Due Date (if known)
-
Month
-
Day
Year
Date
Have you received pregnancy care this pregnancy?
*
Yes
No
Other
If so, what is the name of your provider?
Have you ever had previous uterine surgery including, but not limited to, c-section?
*
Yes
No
Please share any information about yourself or your pregnancy that you feel is important. You’re also welcome to include any questions you have about the birth center.
Please share any information about yourself that you feel is important. You’re also welcome to include any questions you have about the birth center.
Insurance Information
Who is your insurance carrier (if you are self-pay, please type in "self pay")
*
Subscriber Name
Subscriber Date of Birth
Subscriber's Relationship to Client
Self
Spouse
Domestic Partner
Parent
Other relative
Other
Insurance Plan/ID Number
Insurance Group Number
Upload a photo of the front of insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload a photo of back of insurance card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
How did you hear about the birth center?
*
Please Select
Google
Word of Mouth
Social Media
Previous client
Provider Referral
Referred by birth center client
Sign/drive-by
Brochure
Billboard
Referred by Doula
Other
How do you prefer to be contacted?
*
Please Select
Phone
Email
No Preference
Submit
Should be Empty: