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Prenatal Care
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Doulas
About
Services
Prenatal Care
MIdwifery Care
Family Wellness
Doulas
Staff
Financial
Stories
DONATE
NEWS
Contact
Whole Family Care
Birth Center Tour
Learn More
Tell us more and we will get back in touch with you within 24-48 business hours.
Name
*
First Name
Last Name
Email
*
Phone
(###)
###
####
Can we leave a voicemail at this number?
Yes
No
What services are you interest in from Roots Birth Center
Well Family Care
Well Person Care
Prenatal Care
Waterbirth
Unmedicated/Natural Birth
What is your date of birth? ( or the date of birth of the new client)
MM
DD
YYYY
Birth Services Form Questions
What is your estimated Due Date?
MM
DD
YYYY
What number baby is this for you?
Have you previously had a cesarean/surgical birth?
Yes
No
Have you ever given birth outside of the hospital before?
Yes
No
What payment type are you interested in using for your birth?
Employer Based Insurance
Private Insurance
Community/Group Insurance
Ucare/Medicaid/Medical Assistance
Cash Pay
Is there any medical issues or history you think may be important for us to know?
Is there anything else you'd like us to know about or questions you have that we can answer when we respond?
Wellness Questions
Are there areas of your health you would like to discuss?
Thank you!