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First Name*

Last Name*

Email Address*

Phone*

Class Date*

Mode of Delivery*

Class Time*

Insurance Provider*

Member ID*

Insurance Provider Phone Number*

State*

Glucose Test (HgA1C, Blood Sugar Level OR N/A if not applicable)*

Have you been told your blood sugar level is high during pregnancy? (Applicable to females)*

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Risk Test Score. *

Ethnicity*

Race*

Gender*

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Level of Education*

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Height (Feet and inches)*

Weight (lbs)*

Date of Birth*

How did you hear about us?*

Comments*

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