Birth Center Tours Form
(Fill out 1 form per class)
*= required field
* First name
* Last name
* Address
* City
* State
* Zip code
* Language requirement
Choose one:
English
Spanish
Somali
Hmong
Russian
Other
Other language
* Primary phone
* Email
* Birthdate:
Current Hennepin Healthcare patient?
Yes
No
For your prenatal care, who do you see?
Choose one:
OB
Family Practice
Nurse-Midwife
Don't Know
Other
Other prenatal care
Your clinic name
Choose clinic name:
Hennepin Healthcare
Brooklyn Park Clinic
Richfield Clinic
Whittier Clinic
East Lake Clinic
St. Anthony Village Clinic
Sheridan
North Point
Cedar Riverside
Other
Other clinic name
Is this your first baby?
Yes
No
Due date
* Class desired
Tour the Birth Center
* Class date desired
August 4, 2020 6:30pm
August 18, 2020 6:30pm
September 1, 2020 6:30pm
September 15, 2020 6:30pm
October 6, 2020 6:30pm
October 20, 2020 6:30pm
November 3, 2020 6:30pm
November 17, 2020 6:30pm
December 1, 2020 6:30pm
December 15, 2020 6:30pm
Name/ages of other children
Big Brother/Big Sister only
Age of child/children who need car seats
Car Seat Safety only
Thank you for completing this form!