myWakeHealth -

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

Last Name:

Required

First Name:

Required

Middle Name:

Preferred Name:

Date of Birth:

Required MM/DD/YYYY

Maiden Name:

Race:

Gender:

Required

Marital Status:

Required

Address:

Required

City:

Required

State:

Required

Zip Code:

Required

Email Address:

Primary Phone:

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

Last 4 of Social Security Number:

Required

Religious Preference:

What is your primary spoken language?

Required

Please tell us about any special requirements needed (verbal, visual or hearing impairments, mobility or other needs).

Section Two: Ob-Gyn Provider Information

Last Name:

First Name:

Practice Name:

City:

State:

Section Three: Emergency Contact

Last Name:

Required

First Name:

Required

Address:

City:

State:

Zip Code:

Primary Phone:

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

Relationship with Patient:

Required

Section Four: Primary Insurance

Please have insurance card available to complete this section.

Insurance Name:

Insurance Address:

City:

State:

Zip Code:

Insurance Phone Number:

###-###-####

Policy Number:

Group Number:

Policy Holder's Name:

Last 4 of Policy Holder's Social Security Number:

Policy Holder's Birth Date:

MM/DD/YYYY

Policy Holder’s Employer:

Relationship to Patient:

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

Privacy Acknowledgement

I agree

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.

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Labor and Delivery Preregistration Form

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