4512 Post Road, East Greenwich, RI 02818401-884-8273 Name * First Name Last Name Mother's Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Telephone Number * (###) ### #### Email * Baby's Name * First Name Last Name Baby's Date of Birth * MM DD YYYY Select your Health Insurance Plan BCBS of Massachusetts BCBS of Rhode Island The Federal Blue Cross Plan Harvard Pilgrim Tufts United Member ID # * Name of Baby's Pediatrician / Referring Doctor * First Name Last Name * I acknowledge that HBHM require's a credit card number to hold an appointment. Any card or HSA/FSA is fine. A member of our staff will ask for my card number when they call to schedule my appointment. * I acknowledge that there is a $50 cancellation charge for any appointment cancelled in less than 24 hours. Reason for appointment * I am interested in: * In-home Lactation Consult Office Lactation Consult Thank you! Our office will verify your insurance and reach out to schedule your appointment.
