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

Best way to contact you*:
Are you the mother or father/partner?*:

Mother's (Patient's) Information

Has the mother ever been seen at Stanford Hospital and Clinics?*:
Has the mother ever been seen at Lucile Packard Children's Hospital Stanford?*:
Religious Preference *:
Race*:
Ethnicity*:
Future appointment reminder method:

Pregnancy Information

Do you know your last menstrual period?:
Do you have a surrogacy arrangement?*:
Do you have (or plan to have) an adoption arrangement?*:

Mother's Employment

Emergency Contact

Is the Emergency Contact the father/partner?:

Father's/Partner's Information

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

Do you know the father's/partner's Date of Birth?:
Same Address as Mother?:

Father's/Partner's Employment

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

Baby's Pediatrician/Clinic

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

Insurance

Do you have insurance?*:

Pharmacy

 

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:

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.

Please read  Lucile Packard Children's Hospital Stanford's Notice of Privacy Practice 

Please read Your Right to Make Decisions About Your Medical Treatment.

Please read Patient Rights and Responsibilities.