Established Patient, OB Packet

Congratulations on your pregnancy!
We are excited to be providing your Obstetrical care at Alliance ObGyn. We encourage you to begin taking an over the counter prenatal vitamin that is high in folic acid.

For routine OB care:

Most patients will be seen first around 7-9 weeks for a Confirmation of Pregnancy Ultrasound and Provider visit. This visit will be followed by an Intake appointment with our RN between 8-10 weeks.
Following the RN Intake visit, you will see your doctor for your Initial OB visit around 11-12 weeks - this is the first opportunity to listen to the heartbeat by Doppler.

If you are experiencing any issues prior to your scheduled appointments, please call or text our office at 517-484-3000 and we will be happy to schedule a Doctor's visit for you. Please be aware that any appointments related to your pregnancy prior to your Nurse Intake visit may be billed as a separate office visit and may be subjected to your standard Copay or Deductible.

To help us provide you with the best care, we ask that you please take a moment to answer the following questionnaires. Failure to complete this paperwork 48 hours prior to your appointment may result in rescheduling.

Patient Name*

Date of Birth*

Date

Phone Number*

Area CodePhone Number

Disease Screening: The Physicians and Midwives at Alliance Obstetrics & Gynecology in addition to The American College of Obstetricians and Gynecologists (ACOG) and the Michigan Department of Health and Human Services (MDHHS) recommend that all pregnant women undergo testing for HIV, Syphilis, Hepatitis B (in first trimester prior to 12 weeks and third trimester after 28 weeks), Hepatitis C, Urine Drug Screen, Gonorrhea and Chlamydia. This is universal testing and is not based on risk factors. If you don't do these tests during pregnancy, your pediatrician will recommend additional screening and treatments for your newborn.

I agree to recommended screenings.I decline the recommended screenings.

Please answer the following questions about your personal history as well as your family history.

Pregnancy History Form

Do you or the baby’s father have a personal or family history of*

	Yes	No
Spina Bifida (open spine)
Hemophilia
Muscular Dystrophy
Cystic Fibrosis
Blood clots
Sickle cell anemia or carrier status
Ashkenazi Jewish Ancestry
Two or more miscarriages
Congenital heart defect
Mental impairment
One genetic or chromosomal issue

*If yes, please provide details:

Mother's Race*

Mother's Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoRefused to report

Race and ethnicity of the father of the baby:

Please complete the following table about your PERSONAL pregnancy history.

	Miscarriage, termination, or type of delivery	Weeks gestation at delivery/end of pregnancy	Infant’s Birth Weight	Complications (with pregnancy or delivery)	Place of delivery/delivering physician	Gender	Name
First pregnancy
Second pregnancy
Third pregnancy
Fourth pregnancy
Fifth pregnancy
Sixth pregnancy

In the past year, how often have you used the following:*

	Never	Once or twice	Monthly	Weekly	Daily or almost daily
Alcohol, 4 or more drinks per day
Tobacco Products
Prescription drugs for non-medical reasons
Illegal drugs

Treatment and Testing During Pregnancy
During your pregnancy, you will be scheduled for routine visits with providers at Alliance OB/GYN. These appointments allow your provider to monitor the health of you and your baby. They also allow your provider to screen for potential complications that may occur in pregnancy, and intervene as early as possible to ensure the best possible outcome for you and your baby.

Additional tests in the form of blood work, ultrasounds, and/or fetal monitoring may be ordered based on your personal history or the way your pregnancy is progressing. Your provider will discuss the purpose of these tests with you in detail and will answer any questions that you may have.

If you are unable to come in for your scheduled appointment for any reason, we encourage you to reschedule as soon as possible. If you do not want to keep your recommended appointments for either routine visits or testing, you will be encouraged to schedule an appointment to discuss your decision with your provider.

All appointments and tests are to promote the healthiest outcome for you and your baby. Failure to keep any appointments, including ultrasound or monitoring, may seriously jeopardize your health and your baby’s health. This may lead to increased illness or even death of you or your baby.

Delivery at Sparrow Hospital: We have multiple Alliance Physicians covering Sparrow Hospital to provide care during your delivery and hospital stay. You can learn more about each of us on our website under the Providers page. Although we cannot predict which Alliance provider will be on call the day of your delivery, we do know that you will get exceptional care. We have an Alliance Birth Partnership that reviews our standard of care for delivery.

How to Contact Us: If you have a non-urgent medical question that cannot wait until your next appointment, please contact our nurses through your Alliance patient portal. We are also available by phone for urgent medical issues. The operator will send your information to the nurses and you will receive a phone call back. For emergent issues, head directly to the hospital.

Upload pictures of the front and back of your insurance card. *Make sure the picture is a tight crop of your insurance cards without extra background.

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You can select multiple files.

Upload pictures of the front and back of your Driver's License, Passport or State ID.

Browse Files

You can select multiple files.

Primary Insurance:*

Subscriber's Name:*

Subscriber's Date of Birth:*

Date

Patient relationship to Subscriber:*

If patient is a minor, name of Guarantor:

If patient is a minor, Guarantor's Date of Birth:

Date

Insurance Enrollee, Subscriber or Policy ID #:*

Subscriber's Employer:*

Secondary Insurance:

Secondary Insurance Subscriber's Name:

Secondary Insurance Subscriber's Date of Birth:

Date

Secondary Insurance Patient relationship to Subscriber:

Secondary Insurance Enrollee, Subscriber or Policy ID#:

Secondary Insurance Subscriber's Employer:

Do you have a Secondary Medicaid Insurance Plan?*

YesNo

If you pick up a secondary Medicaid plan during your pregnancy, it is your responsibility to inform Alliance OBGYN. Please note that Alliance OBGYN does not bill Medicaid. However Sparrow Hospital will bill Medicaid for their portion of your delivery/services. Therefore it is important to let our team know if you have Secondary Medicaid coverage.

Signature*

OB Screening and Testing Information

Insurance Information