{"id":1017,"date":"2020-02-17T20:24:10","date_gmt":"2020-02-17T20:24:10","guid":{"rendered":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center-llc\/?page_id=1017"},"modified":"2026-01-22T14:53:02","modified_gmt":"2026-01-22T14:53:02","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/patient-rescources\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:center bottom;--awb-background-blend-mode:overlay;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:10%;--awb-padding-bottom:10%;--awb-background-color:rgba(255,255,255,0.35);--awb-background-image:url(&quot;https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/ppc__about_hero.jpg&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_5 1_5 fusion-one-fifth fusion-column-first\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;width:20%;width:calc(20% - ( ( 4% + 4% ) * 0.2 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_3_5 3_5 fusion-three-fifth fusion-animated\" style=\"--awb-padding-top:1px;--awb-bg-color:rgba(180, 218, 244, 0.63);--awb-bg-color-hover:rgba(180, 218, 244, 0.63);--awb-bg-size:cover;width:60%;width:calc(60% - ( ( 4% + 4% ) * 0.6 ) );margin-right: 4%;\" data-animationType=\"fadeInDown\" data-animationDuration=\"0.6\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-1 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-one\" style=\"--awb-text-color:#ffffff;--awb-margin-top:30px;--awb-margin-bottom:30px;--awb-margin-top-small:20px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><h1 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:63;line-height:1.1;\"><strong>Patient Forms<\/strong><\/h1><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-2 fusion_builder_column_1_5 1_5 fusion-one-fifth fusion-column-last\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;width:20%;width:calc(20% - ( ( 4% + 4% ) * 0.2 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fullwidth-padding-box\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:7%;--awb-padding-bottom:6%;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-3 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-animated\" style=\"--awb-bg-size:cover;\" data-animationType=\"slideInLeft\" data-animationDuration=\"0.6\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-1\"><p>For your convenience, we have made our patient forms available to you as PDF files. Please print and bring in your completed forms to your appointment along with photo I.D. and insurance information<\/p>\n<p><a href=\"\/wp-content\/uploads\/sites\/41\/2025\/04\/REGISTRATION-PACKET-FINAL-2025-PEMBROKE-PERINATAL.pdf\" target=\"_blank\" rel=\"noopener\">New Patient Registration Forms<\/a><\/p>\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-full-width-sep\" style=\"margin-left: auto;margin-right: auto;margin-top:3%;margin-bottom:20px;width:100%;\"><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-image-element in-legacy-container\" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><img decoding=\"async\" width=\"1300\" height=\"866\" alt=\"Consulting pregnant\" title=\"Consulting pregnant\" src=\"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/patient-forms-image1.jpg\" class=\"img-responsive wp-image-1019\" srcset=\"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/patient-forms-image1-200x133.jpg 200w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/patient-forms-image1-400x266.jpg 400w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/patient-forms-image1-600x400.jpg 600w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/patient-forms-image1-800x533.jpg 800w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/patient-forms-image1-1200x799.jpg 1200w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2020\/02\/patient-forms-image1.jpg 1300w\" sizes=\"(max-width: 1000px) 100vw, 1300px\" \/><\/span><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-3 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fullwidth-padding-box\" style=\"--awb-background-position:center top;--awb-background-blend-mode:overlay;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:8%;--awb-padding-bottom:7%;--awb-background-color:#b4daf4;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-4 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last\" style=\"--awb-bg-size:cover;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-2 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-two\" style=\"--awb-text-color:#b4daf4;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><h2 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:47;line-height:1.2;\"><p style=\"text-align: center;\"><span style=\"color: #000000;\">Patient Feedback<\/span><\/p><\/h2><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-5 fusion_builder_column_1_3 1_3 fusion-one-third fusion-column-first fusion-animated\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;width:33.3333333333%;width:calc(33.3333333333% - ( ( 4% + 4% ) * 0.333333333333 ) );margin-right: 4%;\" data-animationType=\"slideInLeft\" data-animationDuration=\"0.6\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-3 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-three\" style=\"--awb-text-color:#b4daf4;--awb-margin-top:20px;--awb-margin-bottom:20px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><h3 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:27;line-height:1.5;\"><p style=\"text-align: center; font-size: 22px;\"><span style=\"color: #000000;\"><strong>Dilcia C.<\/strong><\/span><\/p><\/h3><\/div><div class=\"fusion-text fusion-text-2\"><p style=\"text-align: center;\"><span style=\"font-weight: 400;\"><i class=\"fas fa-quote-left\"><\/i> I had my first appt. today at Pembroke Perinatal, the experience was superb. From the front desk staff, to our very sweet ultrasound technologist, Marta, and Eileen, everyone was very kind and professional. Dr. Romary was truly excellent and willing to answer any questions we had. Overall wonderful experience!!\u00a0\u00a0<i class=\"fas fa-quote-right\"><\/i><\/span><\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-6 fusion_builder_column_1_3 1_3 fusion-one-third fusion-animated\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;width:33.3333333333%;width:calc(33.3333333333% - ( ( 4% + 4% ) * 0.333333333333 ) );margin-right: 4%;\" data-animationType=\"slideInDown\" data-animationDuration=\"0.6\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-4 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-three\" style=\"--awb-text-color:#b4daf4;--awb-margin-top:20px;--awb-margin-bottom:20px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><h3 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:27;line-height:1.5;\"><p style=\"text-align: center; font-size: 22px;\"><span style=\"color: #000000;\"><strong>Belkis P.<\/strong><\/span><\/p><\/h3><\/div><div class=\"fusion-text fusion-text-3\"><p style=\"text-align: center;\"><span style=\"font-weight: 400;\"><i class=\"fas fa-quote-left\"><\/i>\u00a0\u00a0Nice, courteous and quick service. Dr. Romary is very kind and patient, answers all questions with details and simple\u00a0\u00a0<i class=\"fas fa-quote-right\"><\/i><\/span><\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-7 fusion_builder_column_1_3 1_3 fusion-one-third fusion-column-last fusion-animated\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;width:33.3333333333%;width:calc(33.3333333333% - ( ( 4% + 4% ) * 0.333333333333 ) );\" data-animationType=\"slideInRight\" data-animationDuration=\"0.6\" data-animationOffset=\"top-into-view\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-title title fusion-title-5 fusion-sep-none fusion-title-center fusion-title-text fusion-title-size-three\" style=\"--awb-text-color:#b4daf4;--awb-margin-top:20px;--awb-margin-bottom:20px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><h3 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:27;line-height:1.5;\"><p style=\"text-align: center; font-size: 22px;\"><span style=\"color: #000000;\"><strong>Megha M.<\/strong><\/span><\/p><\/h3><\/div><div class=\"fusion-text fusion-text-4\"><p style=\"text-align: center;\"><span style=\"font-weight: 400;\"><i class=\"fas fa-quote-left\"><\/i>\u00a0\u00a0Had great experience, Dr.Romary and her staff is great. So courteous all are. Each appointment I looked forward too as they gave detailed information and answered all my questions on baby growth. I had gestational diabetes and with that too, Dr. Romary guided me well to manage it with diet. She followed up to make sure my sugars were in limits and it will not affect baby\u2019s growth. Love this place!!\u00a0\u00a0<i class=\"fas fa-quote-right\"><\/i><\/span><\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-4 hundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-equal-height-columns wh2footerlogos\" style=\"--awb-border-sizes-top:0px;--awb-border-sizes-bottom:0px;--awb-border-sizes-left:0px;--awb-border-sizes-right:0px;--awb-border-color:#B4DAF4;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:0px;--awb-padding-right:0px;--awb-padding-left:0px;--awb-background-color:#f0f3f6;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-8 fusion_builder_column_1_1 1_1 fusion-one-full fusion-column-first fusion-column-last fusion-column-no-min-height\" style=\"--awb-padding-top:0px;--awb-padding-right:0px;--awb-padding-left:0px;--awb-bg-blend:overlay;--awb-bg-size:cover;--awb-border-color:#B4DAF4;--awb-border-bottom:15px;--awb-border-style:solid;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-9 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-first wh2footerlogo\" style=\"--awb-padding-top:40px;--awb-padding-left:12%;--awb-bg-blend:overlay;--awb-bg-size:cover;width:50%;width:calc(50% - ( ( 4% ) * 0.5 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-column-content-centered\"><div class=\"fusion-column-content\"><div class=\"fusion-image-element in-legacy-container\" style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-2 hover-type-none\"><a class=\"fusion-no-lightbox\" href=\"\/pembroke-perinatal-center\/\" target=\"_self\" aria-label=\"Pembroke Perinatal center logo\"><img decoding=\"async\" width=\"270\" height=\"100\" alt=\"Pembroke Perinatal center logo\" src=\"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2021\/06\/Pembroke-Perinatal-center-logo.png\" class=\"img-responsive wp-image-1082\" srcset=\"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2021\/06\/Pembroke-Perinatal-center-logo-200x74.png 200w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2021\/06\/Pembroke-Perinatal-center-logo.png 270w\" sizes=\"(max-width: 1000px) 100vw, 270px\" \/><\/a><\/span><\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-10 fusion_builder_column_1_2 1_2 fusion-one-half fusion-column-last wh2footerlogo\" style=\"--awb-padding-top:40px;--awb-padding-right:4%;--awb-bg-blend:overlay;--awb-bg-size:cover;width:50%;width:calc(50% - ( ( 4% ) * 0.5 ) );\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-column-wrapper-legacy\"><div class=\"fusion-column-content-centered\"><div class=\"fusion-column-content\"><div class=\"fusion-image-element fusion-image-align-right in-legacy-container\" style=\"text-align:right;--awb-max-width:270px;--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-3 hover-type-none\" style=\"margin-left:25px;float:right;\"><a class=\"fusion-no-lightbox\" href=\"https:\/\/www.toplinemd.com\/\" target=\"_blank\" aria-label=\"TopLine MD-RegisterR_Stacked_Logo_rgb_color\" rel=\"noopener noreferrer\"><img decoding=\"async\" width=\"1576\" height=\"376\" src=\"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color.png\" alt class=\"img-responsive wp-image-1173\" srcset=\"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-200x48.png 200w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-400x95.png 400w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-600x143.png 600w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-800x191.png 800w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color-1200x286.png 1200w, https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-content\/uploads\/sites\/41\/2026\/03\/TopLine-MD-RegisterR_Stacked_Logo_rgb_color.png 1576w\" sizes=\"(max-width: 1000px) 100vw, 600px\" \/><\/a><\/span><\/div><\/div><\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n<\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":1166,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1017","page","type-page","status-publish","hentry"],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/pages\/1017","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/comments?post=1017"}],"version-history":[{"count":0,"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/pages\/1017\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/pages\/1166"}],"wp:attachment":[{"href":"https:\/\/www.toplinemd.com\/pembroke-perinatal-center\/wp-json\/wp\/v2\/media?parent=1017"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}