New patients inquiring about care, please fill out form below (required) 1. When is your estimated due date (if known): 2. Where do you live? (please include city and cross-streets): 3. Do you have any health conditions?: 4. Are you taking any medications?: 5. Do you have any children? If yes, did you have any complications with your pregnancy/delivery?: 6. Where are you planning to birth? (home or hospital): 7. Is there anything else you would like us to know?: