Name: | DOB: | MRN: | PCP:

Birth Certificate Registration Form

For medical emergencies, please call 911.

We strongly encourage you to fill out our online birth certificate registration form. This will save you some paperwork after your delivery. We know the immediate postpartum period valuable bonding time and you would much rather be snuggling your sweet little one!

The State of North Carolina Vital Records Office requires these questions to be completed for your child’s birth certificate application. The birth certificate is a legal document that proves your child’s age, citizenship, and parentage. It is essential this form is completed accurately and thoroughly. Any missing information, such as the baby’s name if you are still undecided, will be obtained by Vital Records staff member once you arrive on the postpartum unit.

Please note: This form resets after 5 minutes of no activity.

Section One: Contact Information

Required

Required

Required ###-###-####

Section Two: Child's Information

Required MM/DD/YYYY

Have you determined baby's legal name?
Section Three: Baby's Legal Name

Do you want a Social Security Number issued for your baby?

Required

Section Four: Birth Person's Information
Please put mother's complete full name. (First, Middle, and Last Name)

Required

Required

Is your address outside the US?
Is your mailing address the same as your residence address?

Required

Required MM/DD/YYYY

Required

Is your household / residence inside the incorporated limits of your city or town?

Required

Did you receive WIC benefits during pregnancy?
Did you smoke cigarettes before and/or during this pregnancy?
Section Five: Marital Status of Birthing Person

Required

MM/DD/YYYY

Is the Other Parent's address different than the Mother's address?
Is the Other Parent's address outside the US?
Is your mailing address the same as your residence address?

Must agree to Atrium Health Wake Forest Baptist Privacy Practices below.

Privacy Acknowledgement

The Atrium Health Wake Forest Baptist Notice of Privacy Practices states how we may use and disclose your protected health information. By submitting this information, you (or your legal representative) agree that you have been offered the opportunity to review the Atrium Health Wake Forest Baptist Notice of Privacy Practices , which has been revised as of August 23, 2018.



Important reminder: If you are not legally married, the other parent will need to be present on the day of discharge to complete the birth certificate application. Both parents will need a form of identification (a driver’s license is sufficient) in order to have the Affidavit of Parentage notarized by The Birth Center staff.



Atrium Health Wake Forest Baptist employs security measures to safeguard online transactions; personal information provided via the Atrium Health Wake Forest Baptist website is stored in a secured database and always sent via an encrypted Internet channel. For more information regarding our website policies and agreements, including our access agreement and website privacy statement, please see: Website Policies.