Prenatal Visit

Northwest Suburban Pediatrics

Please correct the errors described below.

Today's Date:

Due Date:

Parent Name:

Obstetrician:

Hospital where baby will be delivered:

Congratulations! With a new baby on the way there are so many decisions and choices to make - including selecting a pediatrician. We hope you find this visit informative. We encourage you to ask any questions you may have about your baby's health care.

How did you learn about our practice?

Is this your first pregnancy?

Yes No

Have you had any complications with this pregnancy?

Yes No

If yes, please explain:

Do you have other children?

Yes No

Do you plan to vaccinate your child according to the recommended schedule?

Yes No Unsure

How do you plan to feed your newborn?

Formula

Breast

Unsure

What insurance will the baby have?

Is there anything else you would like us to know?

Your information will be encrypted.

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