Today's Date *

MM

DD

YYYY

Full Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Appointment Concerns/Types *

What are some of your needs for this appointment?

Annual Exam/PAP Smear

Fertility Consultation

Contraceptive Consultation/IUD interest

Menopause Care

Other

Care with ABC *

I understand Atlanta Birth Center (ABC) is a freestanding, out-of-hospital healthcare facility for low risk prenatal clients guided by the midwifery model of care with Certified Nurse Midwives. I understand that scheduling a visit with ABC does not mean I would automatically be accepted as prenatal care client with ABC. I understand that this visit is a separate stand-alone appointment.

I have read and understand the above statement.

Cost of my Appointment *

Our in-network insurance carriers are Amerigroup Medicaid, United Healthcare, and Aetna for office visits. If you have any of these insurances, please email the front and back of your insurance card to admin@atlantabirthcenter.org We will collect your copay for in-network insurance. If you have Amerigroup, we will NOT collect any out-of-pocket cost from you. If you have an out-of-network insurance or are self-pay, your visit will be $325. Please contact us if you need an income-based, financial assistance application.

I have read and understand the above statement.