Orientation Sign Up Orientation of Jazz Birth Center of ManhattanAll Orientation sessions are held weekly by ZOOM session only. You will receive a confirming email for Orientation with the Zoom link and receive another email reminder on or before the day of Orientation. We accept transfers in pregnancy at all stages, but only as approved by the Clinical Team that you are healthy and low risk. Please note that we do not accept pregnant people who have had a previous cesarean section or presently pregnant with twins. We look forward to 'meeting' you on Zoom. Todays 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 use this number to contact you about your appointments and health information. Please advise any alternative number of contact to the office personnel. Alternate PhoneWe may use this number to contact you about your appointments and health information. If you have any concerns, please speak to our office staff . Email* Enter Email Confirm Email You will receive a confirmation notice at this e-mail address. If you receive care at Brooklyn Birthing Center or Jazz Birth Center, you may receive an occasional e-mail notification.InsuranceDo you have insurance coverage?*YesNoIf you have insurance, what is your plan called* Please be as specific as possible, as many insurance companies offer multiple plans.(PPO, HMO, SharePlan, Essential, Gold, Silver, etc.)Medicaid Managed Care Plan*YesNoDo you have coverage through a Medicaid Managed Care Organization?Are you applying for Medicaid at this time?YesNoInsurance card Drop files here or Accepted file types: jpg, gif, png, pdf, webm. Please upload a copy of your insurance card (front and back).PregnancyAre you currently pregnant?*YesNoIf not, are you planning a pregnancy?YesNoPlease indicate the number of previous births?* If you have given birth in the past, where did you deliver?If you had a cesarean section?*YesNoOur protocols do not allow attempting labor after a cesarean section in the birth center. Feel free to contact us if you need a assistance in 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, you will be asked to send in your medical records for review.If Yes, please indicate the provider(s) you have seen for this pregnancy?Additional InformationHow did you learn about Brooklyn Birthing Center or Jazz Birth Center? (Check all that apply) Internet Search for "birthing center," "midwives," etc. Internet Search for Jazz Birth Center of Manhattan American Association of Birth Centers Directory Facebook, Instagram or Twitter My provider delivers at the Birth Center Doula Friend who was a client Yelp or other reviews site online forum An ad on the internet or in a publication Other Appointment TimeSelect Time*Thursday, 4/22 from 7:00 - 8:30 PMSunday, 4/25 from 11:30 - 1:00 PMThursday, 4/29 from 7:00 - 8:30 PMOrientation is held three times a week on Zoom. Clients accepted for care to the Brooklyn Birthing Center or Jazz Birth Center of Manhattan agree to fulfill a Childbirth Education Class and attend other educational programs. 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 the main office at 718-336-4119 or if you need immediate assistance call Georgia at 917-838-4025.CAPTCHA
