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* 1. Name:

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* 2. Phone Number:

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* 3. E-mail Address:

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* 4. Are you an expectant mother with a due date between December 2019 and May 2020?

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* 5. Do you expect or are you planning to deliver at Cone Health?

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* 6. Are you an employee of Cone Health?

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* 7. Which of the following describes how long you have lived in this area (counties of Guilford, Alamance, Rockingham, Randolph and/or Forsyth)?

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* 8. In a typical year, when you aren’t expecting, how often do you or someone in your immediate family use medical services? Please include primary care visits, specialists, urgent care visits, or emergency services.

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* 9. How would you like to participate in this program?

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