Labor and Delivery Pre-Admission Online Form

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Part 1: Online Pre-Registration Form

If you have any questions about this form, please call the Admitting office at (650) 497-8229.

Your Information

First Name*:

Last Name*:

Phone*:

Email*:

Confirm Email*:

Confirmation Email does not match

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

Please Enter Christian*:

Please Enter Other*:

State/Country of Birth*:

Race*:

American indian Asian Black Native Hawaiian/Pacific Islander White Other

Other

Ethnicity*:

Hispanic Non Hispanic

Preferred Language*:

Interpreter Required*:

Yes No

Future appointment reminder method:

Email Phone Text Decline

Pregnancy Information

Due Date (mm/dd/yyyy)*:

Do you know your last menstrual period?:

Yes No

Last Menstrual Period (mm/dd/yyyy)*:

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*:

Company Name*:

Address 1*:

Address 2:

City*:

State/Province*:

Country*:

Zip/Postal Code*:

Work Phone #:

Occupation:

Emergency Contact

Is the Emergency Contact the father/partner?:

Yes No

Name*:

Address 1:

Address 2:

City:

State/Province:

Country:

Zip/Postal Code:

Phone #*:

Home Cell

Phone #:

Home Cell

Date of Birth (mm/dd/yyyy):

Relationship to Patient*:

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

Date of Birth (mm/dd/yyyy):

State/Country of Birth:

Same Address as Mother?:

Yes No

Home Address 1:

Home Address 2:

City:

State/Province:

Country:

Zip/Postal Code:

Phone #:

Home Cell

Phone #:

Home Cell

Email:

Father's/Partner's Employment

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

Employment Status:

Company Name:

Address 1:

Address 2:

City:

State/Province:

Country:

Zip/Postal Code:

Work Phone #:

Occupation:

Baby's Pediatrician/Clinic

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

Yes No

Medical Group/Clinic Name*:

Pediatrician's Name*:

Address 1*:

Address 2:

City*:

State/Province*:

Country*:

Zip/Postal Code*:

Phone #*:

You may select "No" for now, but, you still must pick a doctor for your baby and give the name of your pediatrician to our Admitting team.��Your registration is not considered complete until you have done this.
To choose a Stanford pediatrician, please:

Visit our��website
Decide which doctor you'd like your baby to see
Call the pediatrician to confirm they are accepting new patients
Call or email our Admitting team to give them the name of your pediatrician

Insurance

Do you have insurance?*:

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

I will pay out of pocket Please have a financial advisor contact me.

Insurance Type*

Health Plan (e.g. Blue Cross, Kaiser, Unitedhealthcare) Medi-Cal Medicare

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Primary Insurance

Type of Health Plan*:

HMO - Health Maintenance Organization PPO - Preferred Provider Organization EPO - Exclusive Provider Organization POS - Point of Service plan I Don't Know

Insurance Company Name*:

Subscriber's Name*:

Are you adding the baby to this insurance plan?*:

Yes No

Insurance Claims Address 1:

Insurance Claims Address 2:

City:

State/Province:

Country:

Zip/Postal Code:

Phone #:

Subscriber's ID/Policy #*:

Group #/Account #:

Do you have secondary insurance?:

Yes No

Secondary Insurance

Type of Health Plan*:

HMO - Health Maintenance Organization PPO - Preferred Provider Organization EPO - Exclusive Provider Organization POS - Point of Service plan I Don't Know

Insurance Company Name*:

Subscriber's Name*:

Are you adding the baby to this insurance plan?*:

Yes No

Insurance Claims Address 1:

Insurance Claims Address 2:

City:

State/Province:

Country:

Zip/Postal Code:

Phone #:

Subscriber's ID/Policy #*:

Group #/Account #:

Medi-Cal Information

ID #*:

Issue Date (mm/dd/yyyy):

Eligibility Worker Name:

Eligibility Worker Phone #:

Medicare Information

ID #*:

Issue Date (mm/dd/yyyy):

Eligibility Worker Name:

Eligibility Worker Phone #:

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.��