Based on your location, this form is not available. To better assist you in your healthcare needs, please call (210) 297-7000.
<survey><openingText>Before I register you for classes, I would like to collect some additional information regarding your pregnancy.</openingText><closingText>REP NOTE:
Please enroll into classes.</closingText><webHeader></webHeader><webFooter></webFooter><displayOpening>Yes</displayOpening><surveyLines><line><link>2900</link><question>What is your physician's name?</question><prompt></prompt><internetable>Yes</internetable><required>Yes</required><dateResponse>No</dateResponse><numberResponse>No</numberResponse><noteResponse>Yes</noteResponse><checkboxResponse>No</checkboxResponse><codeResponse>No</codeResponse></line><line><link>2897</link><question>What is your due date?</question><prompt></prompt><internetable>Yes</internetable><required>Yes</required><dateResponse>Yes</dateResponse><numberResponse>No</numberResponse><noteResponse>No</noteResponse><checkboxResponse>No</checkboxResponse><codeResponse>No</codeResponse></line><line><link>2901</link><question>Who is your partner/coach?</question><prompt></prompt><internetable>Yes</internetable><required>Yes</required><dateResponse>No</dateResponse><numberResponse>No</numberResponse><noteResponse>Yes</noteResponse><checkboxResponse>No</checkboxResponse><codeResponse>No</codeResponse></line><line><link>2898</link><question>Which hospital are you planning to delivering?</question><prompt></prompt><internetable>Yes</internetable><required>Yes</required><dateResponse>No</dateResponse><numberResponse>No</numberResponse><noteResponse>No</noteResponse><checkboxResponse>No</checkboxResponse><codeResponse>Yes</codeResponse><codeOptions><option><code>4986</code><description>East Campus</description><skipToLink>2902</skipToLink></option><option><code>4985</code><description>Memorial Campus</description><skipToLink>2902</skipToLink></option><option><code>5151</code><description>Transmountain Campus</description><skipToLink>2902</skipToLink></option><option><code>4987</code><description>William Beaumont Army Med Ctr</description><skipToLink>2902</skipToLink></option><option><code>4988</code><description>Other</description><skipToLink>2902</skipToLink></option></codeOptions></line><line><link>2902</link><question>What is the name of your insurance?</question><prompt></prompt><internetable>Yes</internetable><required>Yes</required><dateResponse>No</dateResponse><numberResponse>No</numberResponse><noteResponse>Yes</noteResponse><checkboxResponse>No</checkboxResponse><codeResponse>No</codeResponse></line></surveyLines></survey>