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View A Miracle - Intake Form

Please fill out the intake form before your visit. If you don’t, you’ll have to do it when you get here, and others may go in before you. We accept Cash, Visa, Mastercard, Discover and Apple Pay [3% surcharge for credit cards]. We DO NOT accept any insurances.

Date
Month
Day
Year
Have you been to View A Miracle before?
Yes
No
LMP (first day of last menstrual cycle) if known
Month
Day
Year
Baby's Due Date (if known)
Month
Day
Year
Do you need a medical report (An extra $60) for your doctor/midwife?
Yes
No
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How did you hear about us?
Today's date and time
Month
Day
Year
Time
HoursMinutes
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Home | More Questions? See our Frequently Asked Questions.

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