Orientation Sign Up BasicsTodays Date* Date Format: MM slash DD slash YYYY Name* First Last Date of Birth* MM DD YYYY Your Partner or Spouse's NameContact InformationAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*We may use this number to contact you about your appointments and health information. If you have any concerns, please speak to someone in our office. Email* You will receive a confirmation notice at this e-mail address after completing this form. If you decide to receive care at BBC, you will receive occasional e-mail notifications.InsuranceDo you have insurance?*YesNoIf you have insurance, what is your plan called (example: "Emblem HIP PPO")? Please be as specific as possible, as many insurance companies offer multiple plans.*Is your plan a Medicaid managed care plan?*YesNoDo you plan on applying for prenatal Medicaid?YesNoPregnancyAre you currently pregnant?*YesNoIf no, are you planning a pregnancy?YesNoHow many times have you given birth in the past?*If you have given birth in the past, where did you deliver?Have you had a c-section?*YesNoUnfortunately, we do not attend vaginal births after c-sections (VBACs) at Brooklyn Birthing Center. Feel free to contact us if you need a referral.What was the first day of your last menstrual period?What is your estimated due date?*Have you already received prenatal care for this pregnancy?*YesNoIf you have had any prior care for this pregnancy, we will need to review your prenatal records before scheduling your first visit with a midwife.If Yes, what provider(s) have you seen?Additional InformationHow did you learn about Brooklyn Birthing Center? (Check all that apply) Internet Search for "birthing center," "midwives," etc. American Association of Birth Centers Directory Choices in Childbirth Directory Facebook or Twitter Online forum E-mail listserv Yelp or other reviews site Saw BBC table at a community event Flyers or postcards An ad in a newspaper or magazine Friend who was a client Friend who is healthcare professional Other Appointment TimeSelect Time*Friday, 5/24 from 6 - 7:30 PMTuesday, 5/28 from 6 - 7:30 PMMonday, 6/3 from 6 - 7:30 PMSunday, 6/9 from 2 - 3:30 PMFriday, 6/21 from 6 - 7:30 PMFriday, 6/28 from 6 - 7:30 PMWe usually host at least one orientation each week. Please check back soon for more dates. If you are more than 28 weeks pregnant and none of the dates below work for you, please e-mail info@brooklynbirthingcenter.com. Patients who transfer their care to the Brooklyn Birthing Center must complete a Childbirth Education Class to deliver here. Note: If at all possible, please bring anyone else who may be part of your decision-making process. Partners, family members (including children), and labor support team members are welcome. If you have any questions, or if you need to reschedule your orientation, please call us at 718-376-6655.CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.
