Appointment Form/Request - New Patient Information
ALL OF YOUR INFORMATION WILL BE KEPT CONFIDENTIAL. WE NEVER SHARE YOUR INFORMATION WITH THE HOSPITAL, OTHER AGENCIES OR INDIVIDUALS WITHOUT YOUR WRITTEN PERMISSION. THE GOAL OF OUR CLINICS IS TO ENSURE THE HEALTH AND SAFETY OF OUR PATIENTS AND THEIR FAMILIES.

Do you have questions for the receptionist? - you can TEXT our main line at (321) 221-1086 or email your questions to  appointment@commonsensechildbirth.org for quick responses.

Your message will be answered within 24-48 hours.

If you have an EMERGENCY, go to the nearest hospital or call 911.

OFFICE NEW ADDRESS: 213 S Dillard St., Ste 310

Winter Garden, FL 34787



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Email *
First Name *
Last Name *
Date of Birth
 *
MM
/
DD
/
YYYY
Phone Number *
Address *
City *
State
 *
Zip code
 *
Email
 *
Can you pay for your maternity care?
 *
Insurance *
Identification number *
Group number *
Your insurance, phone number (for verification)


 *
Last menstrual period
 *
MM
/
DD
/
YYYY
Indicate the month and approximate year your baby will be born or how many weeks pregnant you are now *
Do you have any medical concerns? *
Have you had a previous cesarean section? *
Where would you like to give birth to your baby? *
Choose Natural Birth at our Winter Garden Center (Includes discounted pricing, same day home discharge, baby's birth certificate and social security number filed with the state of Florida) $3000 package price
South Lake Hospital, Clermont
Winnie Palmer Hospital, Orlando
Advent Hospital for Women, Orlando
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