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 340

Winter Garden, FL 34787



Email *
Nombre *
Apellido *
Fecha de nacimiento

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MM
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DD
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YYYY
Numero de teléfono *
Dirección (número y nombre de la calle) *
Ciudad
Estado
 *
Código postal
 *
Correo Electrónico
How are you going to pay?
 *
Nombre de Seguro/Tipo *
Numero de Identificación de Miembro *
Numero de grupo de su seguro *
Your insurance, phone number (for verification)


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Fecha de su última menstruación
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MM
/
DD
/
YYYY
Indique el mes y el año aproximado en que nacerá su bebé o cuántas semanas de embarazo tiene ahora *
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
Elige hospital - South Lake Hospital, Clermont
Elige hospital - Winnie Palmer Hospital, Orlando
Elige hospital - Advent Hospital for Women, Orlando
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