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Name*

Name

Date of Birth*

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Street Address Address Line 2 City State ZIP Code

What are you looking for?*

Pregnancy & Birth Care

Wellness Care

Lactation Support

Orientation Session

Infusion Therapy

Other

Health Health Insurance Plan & ID number*

Are you pregnant?

Due Date*

(if pregnant)

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Have you ever experienced any of the following issues:

Cesarean Birth

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High Blood Pressure

If you have had any care elsewhere, please indicate what you have completed:

First trimester ultrasound

Anatomy ultrasound

Initial bloodwork

Screening for gestational diabetes

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Contact & Hours

414 Virginia St
Buffalo, NY 14201
Office: 716.427.4541
Fax: 844.884.3605
christina@coitbc.com

Monday: 9AM – 7:30PM
Thursday: 7:30AM – 4PM
Tuesday & Wednesday: Staff only
Friday: Closed

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