Start Prenatal Care Form
Thank you for your interest in starting your prenatal care at The Midwife Center. Our goal is to offer you high-quality, client-centered pregnancy and wellness care. Please complete the form below once you've read the steps on the Start Prenatal Care page on our website. Our goal is to respond to your request to establish prenatal care within 3-5 business days.

If you are planning your first out-of-hospital birth or if you're unsure where you'd like to have your baby, please schedule an orientation if you haven't scheduled one already. You may schedule by calling the front office at 412.321.6880 and press 3.
You do not have to establish care for pregnancy verification and can just call the front office for that type of appointment- 412.321.6880 and press 3.

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

Last Name *
Your answer
First Name *
Your answer
Date of Birth *
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Phone Number *
Your answer
Email Address *
We will use this email address to confidentially contact you about your care.
Your answer
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.
Your answer
Estimated due date?
NOTE: If you are 20 weeks pregnant or more, we must review medical records from your current provider before we can schedule your first prenatal appointment. This process can be lengthy at times. We recommend physically obtaining your records and bringing/faxing them to The Midwife Center as soon as possible. Our fax number is 412.321.7070.
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Have you had a c-section in the past? *
Please enter your height (e.g. 5' 4") *
Your answer
Please enter your weight at time of conception (e.g. 135lbs) *
Your answer
What is your preferred birth site location? *
Please be aware that we are unable to do home deliveries.
What is your health insurance carrier? *
The Midwife Center is in-network with most private insurance and medical assistance plans. If you do not have insurance, we can talk to you about your options including self-payment for services.
Required
How did you verify your pregnancy? *
Are you a previous client? *
If yes, approximately how long ago were you a client? *
Please list any names you have been previously known by within our care.
Your answer
How did you hear about The Midwife Center?
Your answer
Brief Notes:
Please note we cannot address medical concerns or answer clinical questions unless you are an established client. We appreciate your understanding.
Your answer
What is you preferred form of communication? *
Is it okay to leave voicemails? *
Have you had any prenatal care for this pregnancy yet? *
Your answer
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