Orientation Sign Up A note about OrientationCurrently all Orientations are held online. After signing up, you will receive a email confirming Orientation with information about in person Orientations which you can ignore. For more information about the changes to Orientations and prenatal care at the Brooklyn Birthing Center at this time, please visit the main page of our website and scroll down to News and Testimonials. We currently are accepting transfers up to 40 weeks of pregnancy. You cannot transfer to our practice if you are pass this gestational age. We currently have not restricted the amount of patients who are transferring into our care for delivery at the facility.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 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. Alternate PhoneWe 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.Are you interested in being a Volunteer?*YesNoInsuranceDo 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*Late transfer (36 weeks + pregnant)Tuesday, 3/31 from 6 - 7:30 PMSunday, 4/5 from 2 - 3:30 PMTuesday, 4/14 from 6 - 7:30 PMTuesday, 4/21 from 6 - 7:30 PMTuesday, 4/28 from 6 - 7:30 PMWe usually host at least one orientation each week. Please check back soon for more dates. Patients who transfer their care to the Brooklyn Birthing Center must complete a Childbirth Education Class to deliver here and first time mothers should inquire about a Doula if they do not have one already. Late transfer patients should try to obtain their medical records before they come into orientation. Orientations during the COVID-19 outbreak will be held online via Zoom. You will receive a link to the orientation on the day it is scheduled. 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.CAPTCHAUntitledFirst ChoiceSecond ChoiceThird ChoiceUntitledUntitledPost BodyPost Custom FieldPost Custom FieldSection Break This iframe contains the logic required to handle Ajax powered Gravity Forms.