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Patient Information & Pregnancy Questionnaire
  
* Required

Patient Information & Pregnancy Questionnaire











PARTNER INFORMATION (if the patient is pregnant, then “partner” is the father of the pregnancy)






PATIENT CONTACT INFORMATION AND AUTHORIZATION





No Yes
Cell Home Work
NO YES        If YES, complete below:



  • Patient has the right to revoke permission for the confidential voice mail
  • Patient assumes responsibility for information left on the confidential voice mail

REFERRING DOCTOR OR CLINIC INFORMATION






PREGNANCY AND EXPOSURE INFORMATION

No Yes
No Yes


Since becoming pregnant, have you had any:

(Or if not pregnant please check current exposures)

No Yes
No Yes     
No Yes     
No Yes     
No Yes     

Do you have any of the following conditions?

No Yes
No Yes
No Yes
No Yes
No Yes

ALL OF THE ABOVE INFORMATION IS CORRECT 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
Mercy Hospital Office, 3661 S. Miami Avenue, Suite 610, Miami, FL 33133, Tel: (305) 403-7600, Fax: (305) 403-7663
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
Portofino Professional Bldg- 925 NE 30 Terr, Suite 100, Homestead, FL 33033, Tel: 305-246-0040, Fax: 305-246-0016