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Patient Information & Pregnancy Questionnaire
* Required

Section 1. Patient Information















Section 2.
Partner Information (if the patient is pregnant, then "partner" is the father of the pregnancy)


Section 3.
Pregnancy Information

    Yes  No

Section 4.
Since becoming pregnant, have you had any (or if not pregnant please check current exposure)

Yes  No Yes  No Yes  No
Yes  No Yes  No

Section 5.
Do you have any of the following conditions?

   Yes  No    Yes  No

Section 6.
Confidential or Private Messages

   Yes  No





If there is a phone number at which we may leave confidential messages, please sign the release below:

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I HAVE ANSWERED THE ABOVE QUESTIONS TO THE BEST OF MY KNOWLEDGE

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What our patients say

"I just wanted to say THANK YOU. I have read up on quite a bit of expecting moms experiences with their ultrasounds around the country and they were less then favorable, some horrible. But our (my husband and I) visit to your Baptist office was wonderful. The office is nice and decor is great. The tech was patient and educated. She answered all our questions, some before we even asked. She gave us her undivided attention and took her time. I am looking forward to my next appointment. Great service provided!" Ronnita W.,  Miami

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6200 Sunset Drive, Suite 301, South Miami, FL 33143, Office: (305) 669-9521, Emergency: (305) 669-9521, Fax: (305) 669-9735
11760 S.W. Bird Road, Suite 329, The Atrium Medical Building, Miami, FL 33175, Office: (786) 621-5300, Fax: (786) 621-5303
Mount Sinai Medical Center, Professional Medical Building, 4308 Alton Road, Suite 730, Tel: (305) 403-1234, Fax: (305) 403-0345
Ft. Lauderdale Office, 3107 Stirling Rd, Suite 106, Ft Lauderdale, Fl 33312, Tel: 305-859-7809, Fax: (305) 859-7790
North Shore Medical Ctr. 1190 NW 95 ST, Suite 204, Miami, FL 33150, Office: (305) 691-2180, Fax (305) 691-2182
Hialeah Hospital Medical Arts 777 East 25 ST, Suite 402, Hialeah, FL 33013, Tel: 305-835-7909, Fax: 305-835-9353