Pre-register for Baby's Birth Online

To pre-register, you can submit this online form, download and mail the pdf version, or visit the Admitting Department at Riverside Regional Medical Center anytime during your pregnancy. We recommend that you pre-register for your hospital stay before the 8th month of your pregnancy. 

By pre-registering, you can give us the information we need for your hospital record before itís time for you to come to the hospital. This helps us prepare for your arrival in advance and allows you to focus more completely on having your baby.


How to use this form:
Use the tab key to move from one text box to another. Don't hit the enter key; you might send the form before you're done. When you finish, click Submit at the bottom.

Patient Information
Patient Full Legal Name: Last/First/Middle Initial Social Security Number
Email address Telephone Number
Address: Street/City/State/Zip Code
Sex Race Marital Status Date of Birth
Name of Church You Attend in the Area Religion

Patient Employer Information
Employer's Name Status (Full-time, Part-time, etc.)
Address: Street/City/State/Zip Code Telephone Number

Responsible Party Information
    Same as Patient (Patient is Responsible Party)
Full Legal Name: Last/First/Middle Initial Social Security Number
Address: Street/City/State/Zip Code Telephone Number
Relationship to Patient Date of Birth

Responsible Party Employer Information
Employer's Name Status (Full-time, Part-time, etc.)
Address: Street/City/State/Zip Code Telephone Number

Next of Kin Information
    Same as Responsible Party
Full Name: Last/First/Middle Initial Relationship to Patient
Address: Street/City/State/Zip Code Telephone Number

Insurance Policy #1 Information
Insurance Company Name Insurance Co Phone
Address: Street/City/State/Zip Code Group Name
    Same as Responsible Party (Subscriber is Repsonsible Party)
Subscriber Full Legal Name: Last/First/MI Policy Number
Relationship to Patient Subscriber Date of Birth Subscriber SSN

Insurance Policy #2 Information
Insurance Company Name Insurance Co Phone
Address: Street/City/State/Zip Code Group Name
    Same as Responsible Party (Subscriber is Responsible Party)
Subscriber Full Legal Name: Last/First/MI Policy Number
Relationship to Patient Subscriber Date of Birth Subscriber SSN

Additional Information
Patient Physician Name Physician Name for Baby
Expected Due Date
Do you have an Advance Directive? yes no

  

Thank you!