To make each visit to the hospital easier, a pre-registration form can be completed online using a secure website. This form should be completed by the 20th week of your pregnancy. This pre-registration form collects general information about your due date, your Doctor, your baby's Doctor, as well as some personal information, health insurance information, and medication information. It will also collect details about any additional insurance for semi-private or private accommodation requests that you may have during the admission process.


Childbirth Program Pre-Registration Form

CHILDBIRTH REGISTRATION FORM

date picker image
 
 
 
 
 
 

Personal Info

 
 
 
 
 
 
 
 
 
ext.
 
ext.
 
 

Patient Medication History

 
 
Taking any medications?
 
 
 

My Medications

 

INSTRUCTIONS
Please list below any medications that you are now taking. Include PRESCRIPTION, non-prescription medications and vitamins or supplements. Other examples include: patches, inhalers, drops and medicated creams.

 
I will bring my medications with me
 
 
 
 
 
 
 
 

My Allergies

 
 
Do you have allergies
 
 
 
 
 

Feeding your baby

 
How do you intend to feed your baby?
 
 

Health Insurance

 
 
 

Substitute Decider

 
 
ext.
ext.
 
 

Aditional Insurance for Semi-Private or Private Accommodation Requests

 
 
Relationship to Subscriber
 
 

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