Established Patient, OB Packet

Congratulations on your pregnancy!
We are excited to be providing your Obstetrical care at Alliance ObGyn. We encourage you to begin taking an over the counter prenatal vitamin that is high in folic acid.

For routine OB care:

Your first visit will be around 8 weeks with our Intake Nurse as a TeleHealth visit (if you would prefer to see our Intake Nurse in person please let our scheduling staff know).
You will see your doctor at your 12 week appointment. This is the first opportunity to listen to the heartbeat by Doppler.

If you are experiencing any issues prior to your scheduled Intake appointment, please call or text our office at 517-484-3000 and we will be happy to schedule a Doctor's visit for you. Please be aware that any appointments related to your pregnancy prior to your Nurse Intake visit may be billed as a separate office visit and may be subjected to your standard Copay or Deductible.

After your Nurse Intake appointment you will be contacted by the Alliance OB Patient Liaison to further discuss the billing for your pregnancy based on your individual insurance plan(s).

To help us provide you with the best care, we ask that you please take a moment to answer the following questionnaires. Failure to complete this paperwork 48 hours prior to your appointment may result in rescheduling.

Patient Name*

Date of Birth*

Date

Phone Number*

Area Code Phone Number

Have you received the Covid-19 vaccine?*

YesNo

Please enter the date of your first vaccine.

Date

Please enter the date of your second vaccine (if applicable).

Date

Which vaccine did you receive?*

PfizerModernaJohnson & JohnsonI have not received the vaccine.

First Trimester Dating Ultrasound: We recommend an Early Ultrasound around 8-9 weeks of pregnancy to confirm due date and how many babies are growing. This ultrasound will be scheduled as a seperate appointment that will happen after your RN Intake visit.
This is a screening ultrasound and in the event it, or any other ultrasounds, are not covered by your insurance, you will be responsible for any fees for these services.

*

I consent to a first trimester dating ultrasound.I decline a first trimester dating ultrasound.

Maternal Genetic Carrier Screening: We recommend screening for genetic issues that may be passed down in pregnancy. This involves a blood test for the pregnant woman to see if she is a "carrier" for specific issues. Please review the following: Cystic Fibrosis Carrier Screening, Hemoglobinopathies Screening and Spinal Muscular Atrophy (SMA) Carrier Screening. If you already know your carrier status, you do not need to be retested. Some women with specific risks factors may be offered maternal genetic screening for Fragile X Syndrome Carrier Screening and Ashkenazi Jewish Ancestry Carrier Screening.

*

I consent to carrier screening for Cystic Fibrosis, Hemoglobinopathies and Muscular Dystrophy.I decline maternal genetic carrier screening OR already know my carrier status.

Fetal Genetic Screening: We recommend genetic screening for the fetus in addition to the 20 week anatomy ultrasound of the baby. This is a blood draw for you and does not pose any risk to the baby. Please review the Fetal Genetic Screening Information and Codes.

*

I would like a Nuchal Translucency Ultrasound, Free Cell DNA Test and AFP Test.I decline additional genetic testing.

Disease Screening: The Physicians and Midwives at Alliance Obstetrics & Gynecology in addition to The American College of Obstetricians and Gynecologists (ACOG) and the Michigan Department of Health and Human Services (MDHHS) recommend that all pregnant women undergo testing for HIV, Syphilis, Hepatitis B (in first trimester prior to 12 weeks and third trimester after 28 weeks), Hepatitis C, Urine Drug Screen, Gonorrhea and Chlamydia. This is universal testing and is not based on risk factors. If you don't do these tests during pregnancy, your pediatrician will recommend additional screening and treatments for your newborn.

*

I agree to recommended screenings.I decline the recommended screenings.

Please answer the following questions about your personal history as well as your family history.

Pregnancy History Form

Do you or the baby’s father have a personal or family history of*

	Yes	No
Spina Bifida (open spine)
Hemophilia
Muscular Dystrophy
Cystic Fibrosis
Blood clots
Sickle cell anemia or carrier status
Ashkenazi Jewish Ancestry
Two or more miscarriages
Congenital heart defect
Mental impairment
One genetic or chromosomal issue

*If yes, please provide details:

Mother's Race*

Mother's Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoRefused to report

Race and ethnicity of the father of the baby:

Please complete the following table about your PERSONAL pregnancy history.

	Miscarriage, termination, or type of delivery	Weeks gestation at delivery/end of pregnancy	Infant’s Birth Weight	Complications (with pregnancy or delivery)	Place of delivery/delivering physician	Gender	Name
First pregnancy
Second pregnancy
Third pregnancy
Fourth pregnancy
Fifth pregnancy
Sixth pregnancy

In the past year, how often have you used the following:*

	Never	Once or twice	Monthly	Weekly	Daily or almost daily
Alcohol, 4 or more drinks per day
Tobacco Products
Prescription drugs for non-medical reasons
Illegal drugs

Treatment and Testing During Pregnancy
During your pregnancy, you will be scheduled for routine visits with providers at Alliance OB/GYN. These appointments allow your provider to monitor the health of you and your baby. They also allow your provider to screen for potential complications that may occur in pregnancy, and intervene as early as possible to ensure the best possible outcome for you and your baby.

Additional tests in the form of blood work, ultrasounds, and/or fetal monitoring may be ordered based on your personal history or the way your pregnancy is progressing. Your provider will discuss the purpose of these tests with you in detail and will answer any questions that you may have.

If you are unable to come in for your scheduled appointment for any reason, we encourage you to reschedule as soon as possible. If you do not want to keep your recommended appointments for either routine visits or testing, you will be encouraged to schedule an appointment to discuss your decision with your provider.

All appointments and tests are to promote the healthiest outcome for you and your baby. Failure to keep any appointments, including ultrasound or monitoring, may seriously jeopardize your health and your baby’s health. This may lead to increased illness or even death of you or your baby.

Pregnancy Care Options: We offer three pathways for your OB care: Traditional, Midwife and Centering.** If you are a low risk pregnancy, you may consider choosing the Midwife, Centering Pregnancy or Traditional Care option. HIgh risk women will need to do Traditional Care option with an OB/GYN. Please review our FAQs about Midwifery Care and our FAQs about Centering Care before your Intake Visit.

** Centering option is not currently available due to COVID-19.

Delivery at Sparrow Hospital: We have multiple Alliance Physicians and Alliance Midwives covering Sparrow Hospital to provide care during your delivery and hospital stay. You can learn more about each of us on our website under the Providers page. Although we cannot predict which Alliance provider will be on call the day of your delivery, we do know that you will get exceptional care. We have an Alliance Birth Partnership that reviews our standard of care for delivery.

How to Contact Us: If you have a non-urgent medical question that cannot wait until your next appointment, please contact our nurses through your Follow My Health Alliance patient portal. We are also available by phone for urgent medical issues. The operator will send your information to the nurses and you will receive a phone call back. For emergent issues, head directly to the hospital.

Common Questions:

Financial Documents:

Please review the Alliance Patient Financial Policy.

Name*

First Name Last Name

Signature*

Clear

Copies of signed authorizations are available upon request.

Patient Name*

Patient Number*

Patient Date of Birth*

Date

Usual Provider*

Forms must be brought to the office and payment is due at that time. Forms received via fax or mail may cause delay.
There is a fee for each form that needs to be completed.
The form is typically completed within 7-10 business days from date of payment.
Please ensure that you have only completed the “patient” portion of your form. We are unable to submit forms in which the “physician/provider” portions have been completed (even in part) by someone other than an Alliance Ob-Gyn staff member.
Forms are completed for medically indicated time off work ONLY. Any additional time that you are eligible for under FMLA must be coordinated by you and your employer.

Patient Signature*

Clear

1. If form is for another family member or caregiver of patient, indicate name and relationship to patient.

Name

Relationship

2. What is the reason for your disability?

PregnancyVaginalC-SectionSurgery

Do you require leave for one or both of the following?

Intermittent LeavePost Delivery

3. Date you stopped working:

Date

4. What was your delivery date or expected due date?

Date

NOTE

Once form is completed, how would you prefer we process?

FaxMail FormPick Up – Patient will request upon arrival at Check In desk.

Fax to:

Mail to:

Covid-19 Information

OB Screening and Testing Information

FMLA/Disability Request

Insurance Information