Welcome!   ¡Bienvenida!

Thank you for reaching out to Baby Steps for your maternity care needs! We are honored to support you during this special time.

To schedule an appointment, please answer the following questions. Your information will remain strictly confidential.

It can take up to 10 business days until you receive a call. We understand the wait can be cause for some anxiety, but we promise we are working as fast as we can.

Thank you for your patience! We look forward to assisting you!


Gracias por contactar a Baby Steps para sus necesidades de atención de maternidad. Nos honra poder apoyarla en este momento tan especial.

Para programar una cita, responda las siguientes preguntas. Su información será estrictamente confidencial.

Pueden pasar hasta 10 días hábiles hasta que reciba una llamada. Entendemos que la espera puede generar cierta ansiedad, pero prometemos que estamos trabajando lo más rápido que podemos.

¡Gracias por su paciencia! ¡Esperamos poder ayudarle!
Email *
Full Name/ Nombre completo *
Phone number/ Número de teléfono *
Consent to text? /  ¿Consentimiento para enviar mensajes de texto? *
Required
Date of Birth/ Fecha de nacimiento *
MM
/
DD
/
YYYY
  Preferred Language / Idioma Preferido   *
Do you need an interpreter?/¿Necesita un intérprete? *
Address/ dirección *
ZIP Code/  Código Postal *
Ethnicity/  Origen étnico *
Race/ Raza *
Marital Status /  Estado Civil *
Employment Status / Estado laboral *
Education Level / Nivel de educación
 *
Have you been a patient of ours in the past?/ ¿Has sido paciente nuestra en el pasado? *
Required
Last menstrual period? If unknown, please state why. / Última menstruación? Si se desconoce, por favor, indique el motivo. *
Are your cycles regular or irregular? / ¿Tus ciclos menstruales son regulares o irregulares? *
What is your estimated due date (if known)?/ ¿Cuál es su fecha estimada de parto (si la conoce)?
MM
/
DD
/
YYYY
Have you received prenatal care elsewhere for this pregnancy? (Yes/No)If yes, where? / ¿Ha recibido atención prenatal en otro lugar durante este embarazo? (Sí/No) Si es así, ¿dónde? *
If care was received elsewhere, was imaging done? (yes/no) What was the estimated delivery date from that imaging? / Si recibió atención médica en otro lugar, ¿le realizaron alguna prueba de imagen? (sí/no) ¿Cuál fue la fecha probable de parto estimada según esas pruebas de imagen?
Do you have any high-risk pregnancy concerns or conditions? (Yes/No)If yes, please explain: / ¿Tiene alguna inquietud o condición relacionada con un embarazo de alto riesgo? (Sí/No) En caso afirmativo, explique: *
Do you have any known allergies, including medications? (Yes/No)If yes, please list: / ¿Tiene alguna alergia conocida, incluyendo medicamentos? (Sí/No) En caso afirmativo, por favor, enumere: *
Do you have any chronic health conditions? (Diabetes, Hypertension, etc.)   / ¿Tiene usted alguna condición de salud crónica? (Diabetes, Hipertensión, etc.) *
What is your preferred pharmacy? Phone number? / ¿Cuál es su farmacia preferida? ¿Número de teléfono? *

Baby Steps Daytona tries to provide care for pregnant mothers regardless of insurance status. At this time, however, we are only in-network for private insurances Blue Cross/Florida Blue, Curative, Cigna, and UHC. If you have private insurance that is not one of these (i.e. Florida Health Care, Oscar, and others), we recommend contacting providers in your network as you will likely have a copay for your visits. We CANNOT see Florida Health Care patients, even as out-of-network, at this time. We are in the process of credentialling with other insurance providers, but at this time, we are only in network for the four previously listed. If you have private insurance that is accepted at the clinic at this time, the deductible or office visit copayment as assigned by your insurance plan will be collected at the beginning of each visit. We do not choose the amount for copays and ask, please, for your understanding if it is determined that such charges exist with your insurance.

Failure to read this fully may result in a delay of care in your pregnancy.

Please type your first and last name below to confirm that you have read and understand the above statement.

 *
If you are currently insured, what kind of insurance do you have and what is your member number? / Si actualmente tiene seguro, ¿qué tipo de seguro tiene y cuál es su número de póliza? *
Do you need assistance applying for pregnancy-related benefits or Medicaid?  / ¿Necesita ayuda para solicitar beneficios relacionados con el embarazo o Medicaid? *
Do you have a safe and stable place to live? / ¿Tiene usted un lugar seguro y estable donde vivir? *
Do you have reliable transportation to appointments?  / ¿Dispone de transporte confiable para asistir a sus citas? *
Emergency Contact Name  /Nombre del contacto de emergencia *
Relationship to You / Relación contigo *
Phone Number  / Número de teléfono *

This form helps us gather the information we need to understand your needs and provide the best possible care.

Once you’ve submitted your form:

One of our small but dedicated team members will review your information.

We’ll reach out to you personally to schedule your first appointment (telehealth or in-person).

Please keep an eye on your phone and voicemail so we can connect with you quickly.

Because we’re a small team serving many families, it may take us 7-10 business days to get in touch. Thank you so much for your patience! 💙

Your journey with Baby Steps starts here, and we can’t wait to walk alongside you.

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