Name: | DOB: | MRN: | PCP:

Labor and Delivery Preregistration Form

For medical emergencies, please call 911.

Thank you for choosing Atrium Health Wake Forest Baptist - The Birth Center for your baby's delivery. We encourage you to preregister at least four weeks prior to your due date.

Before you start, please have the following information available:

    • Mother's information, including employer and employer address
    • Emergency contact/father/partner information
    • Name of Ob-Gyn
    • Insurance information

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

Section One: Mother's (Patient's) Information

Required

Required

Required MM/DD/YYYY

Required

Required

Required

Required

Required

Required

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

Required

Required

Section Two: Ob-Gyn Provider Information

Section Three: Emergency Contact

Required

Required

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

Required

Section Four: Primary Insurance
Please have insurance card available to complete this section.

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MM/DD/YYYY

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 information for preregistration, 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: Please be sure to contact your insurance company to ensure coverage for your labor and delivery stay and determine any co-payment or deductible required by your plan.



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.