Well Body and Birth Eligibility Form

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Thank you for considering Well Body & Birth for your pregnancy! At this time, WBB is currently taking clients with due dates of December 2025 and beyond. Please complete the form below once you've read the FAQs on our website. If you are interested in taking a peek of our birth center before or during the intake process, you can use this link to schedule an in-person tour.

The information you provide in this form is kept confidential according to HIPAA law.

First Name *

Last Name *

Date of Birth *

YYYY

Phone Number *

Email Address *

What is your preferred method of communication?

Phone

Clear selection

When was the first day of your last menstrual period?

If you are unsure, have irregular periods, or know the date of conception, please write that in the box below.

When is your estimated due date?

YYYY

How did you verify your pregnancy? *

Urine Test

Blood Test

Ultrasound

Are you currently seeing another provider for your pregnancy? *

Yes

Are you pregnant with multiples (twins, triplets, or more)? *

Yes

Not that you know of

Have you previously given birth? If so, how many live births have you had?

Have you had a c-section in the past?

Yes

Were you diagnosed with an incompetent cervix in the past?

Yes

In previous pregnancies, did you have any of the following conditions: *

Shoulder dystocia

Preterm

Stillbirth or neonatal loss

Placental Abruption

Gestational diabetes

Pre-eclampsia

None of the Above

No previous pregnancies

Required

In the past, have you ever been diagnosed or taken medication for any of the following conditions: *

High Blood Pressure (not pregnancy related)

Diabetes or insulin resistance (not pregnancy related)

Kidney Disease

Heart Disease

Lung Disease (other than asthma)

Epilepsy or seizure disorder

Anemia

Thrombophilia, such as sickle cell anemia, thalassemia, or Factor V Leiden

Auto-Immune Disease

Substance Use Disorder

None of the Above

Required

Who is your insurance provider?

We are not currently in-network with any insurance providers, but we are gathering data to help us move toward offering insurance coverage in the future. If you do not have insurance, we can talk to you about your options, including self-payment for services.

Thank You!

We will review your information to determine your eligibility for prenatal care with WBB. If it is determined that you're eligible, next steps will include a registration fee, an intake form, verification of insurance benefits, and review of current prenatal care records (if applicable).

Please note that we cannot address medical concerns until you are an established patient.

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