Prenatal Well

Request an Appointment

Share a few details about yourself and the type of visit you’re looking for. Our team will review your request and follow up to confirm the best date, time, and location for your appointment.

Need to speak with someone?

For time-sensitive issues, please call 219.232.9050. If this is an emergency, call 911 or go to the nearest emergency room.

Tell us how we can support you

First name

Last name

Date of birth

Mobile phone

Preferred contact method

We may call or text you about your appointment.

Which best describes you right now?

I am currently pregnant I recently had a baby (within 1 year) I am trying to conceive I need gynecologic care (not pregnant)

Type of appointment you’re requesting*

Preferred location

Are you a new patient to Prenatal Well?

Preferred days and times

We’ll do our best to honor your preferences based on availability.

Insurance coverage

Medicaid Private / employer insurance Uninsured / self-pay

Insurance plan name

Member ID (if available)

Briefly share the reason for your visit

How did you hear about Prenatal Well?

Permission to Contact

I give Prenatal Well permission to contact me by phone, text, and/or email about this appointment request and my care. I understand that this form is not monitored 24/7 and should not be used for emergencies. If I am experiencing a medical emergency, I will call 911 or go to the nearest emergency room.

By providing your phone number, you consent to receive text messages from Prenatal Well for purposes related to our services. Message frequency may vary. Message and Data Rates may apply. Reply HELP for help or STOP to unsubscribe. See our Privacy Policy and Terms & Conditions.

After you submit, our team will reach out within 1–2 business days to confirm your appointment.

What happens after I submit?

Once we receive your request:

If we have any questions or need clarification, we’ll reach out by your preferred contact method.

If you need urgent or same-day care

For urgent concerns, please call our office directly. This form should not be used to request same-day appointments or to share urgent medical symptoms.

If you are experiencing heavy bleeding, severe pain, trouble breathing, chest pain, or any concerning symptoms, call 911 or go to the nearest emergency room.

What to bring to your visit

Planning ahead

If you need help with transportation or childcare during your visit, please let us know in your message or when our team calls to schedule you. We’ll do our best to help you find a time that works for you and your family.