Labor and Delivery Pre-Admission Form

Your Information

First Name*:

Last Name*:

Phone*:

Email*:

Confirm Email*:

Best way to contact you*:

Phone Email

Are you the mother or father/partner?*:

Mother Father/Partner No

Mother's (Patient's) Information

Has the mother ever been seen at Stanford Hospital and Clinics?*:

Yes No

Has the mother ever been seen at Lucile Packard Children's Hospital Stanford?*:

Yes No

First Name*:

Last Name*:

Middle Name:

Maiden Name:

Date of Birth (mm/dd/yyyy)*:

Home Address 1*:

Home Address 2:

City*:

State/Province*:

Country*:

Zip/Postal Code*:

Phone*:

Home Cell

Phone:

Home Cell

Email:

Best time to contact you

Marital Status*:

Religious Preference *:

Buddhist Catholic Christian Hindu Islam/Muslim Jewish None Other

State/Country of Birth*:

Race*:

American indian Asian Black Native Hawaiian/Pacific Islander White Other

Ethnicity*:

Hispanic Non Hispanic

Preferred Language*:

Future appointment reminder method:

Email Phone Text Decline

Pregnancy Information

Due Date (mm/dd/yyyy)*:

Do you know your last menstrual period?:

Yes No

Obstetrician (OB)/Clinic*:

Referring MD/Clinic:

Do you have a surrogacy arrangement?*:

Yes No

Do you have (or plan to have) an adoption arrangement?*:

Yes No

Mother's Employment

Employment Status*:

Emergency Contact

Is the Emergency Contact the father/partner?:

Yes No

Father's/Partner's Information

If you do not know the information please enter "Unknown".

First Name:

Middle Name:

Last Name:

Do you know the father's/partner's Date of Birth?:

Yes No

State/Country of Birth:

Same Address as Mother?:

Yes No

Phone #:

Home Cell

Phone #:

Home Cell

Email:

Father's/Partner's Employment

If you do not know the information please enter "Unknown".

Employment Status:

Baby's Pediatrician/Clinic

Have you selected a pediatrician or clinic where you plan to bring your baby?*:

Yes No

Insurance

Do you have insurance?*:

Yes, I have insurance No, I do not have insurance

Pharmacy

Pharmacy Name*:

Address 1*:

Address 2:

City*:

State*:

Country*:

Zip/Postal Code*:

You're almost done with Part 1!

In order to complete Part 2 of your registration, you’ll need to print, sign, and send us copies of:

Required forms (found on the next page)
Your Photo ID
Insurance Card(s) for mother and father/partner
Prescription Card(s) for mother

The complete list of items to send us will be available after you click "Submit".

Submission Method

* Please choose how you will send us these items:

I will email the forms and card copies to: admitting@stanfordchildrens.org I will fax the forms and card copies to: (650) 725-3574 I will mail (or drop off in person) the forms and card copies to:

Lucile Packard Children's Hospital Stanford
Attn: Admitting Department
OB Pre-Registration Forms
725 Welch Rd, Ground Floor, Suite G26
Palo Alto, CA 94304

These last 3 items help ensure you are informed about your privacy and rights while admitted at Lucile Packard Children's Hospital Stanford.

Please click on the underlined links below to read the information. Then, check the box to show that you have read each item.

I have read Lucile Packard Children's Hospital Stanford's Notice of Privacy Practice.

Please read Lucile Packard Children's Hospital Stanford's Notice of Privacy Practice

I have read Your Right to Make Decisions About Your Medical Treatment.

Please read Your Right to Make Decisions About Your Medical Treatment.

I have read Patient Rights and Responsibilities.

Please read Patient Rights and Responsibilities.

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Part 1: Online Pre-Registration Form

Your Information

Mother's (Patient's) Information

Pregnancy Information

Mother's Employment

Emergency Contact

Father's/Partner's Information

Father's/Partner's Employment

Baby's Pediatrician/Clinic

Insurance

Primary Insurance

Secondary Insurance

Medi-Cal Information

Medicare Information

Pharmacy

You're almost done with Part 1!