Childbirth Registration Form

Childbirth Center Classes

Video Experience

Are you pregnant?

Our online pre-registration makes it easy to help us be ready for your special day. Questions? Call us at 760.940.3151.

Expected Date of Delivery
MM slash DD slash YYYY
Obstetrician Name
Pediatrician Name
Primary Care Physician Name
Have you ever had services at Tri-City Medical Center before?*
- Yes
- No
Patient Information
Name*
First Middle Last
Date of Birth*
Month
Day
Year
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Example: (123) 123-1234
Email*
Marital Status
Religious Affiliation
Employment Status*
Employer
Employer Address
Occupation

Next of Kin/Spouse Information
Name*
First Middle Last
Relationship to Patient*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Example: (123) 123-1234
Guarantor Information
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Example: (123) 123-1234
Employment Status
Emergency Contact Information (other than spouse/partner)
Name*
First Middle Last
Relationship to Patient*
Primary Phone*
Example: (123) 123-1234
Secondary Phone
Example: (123) 123-1234

Insurance Information
Insurance Type*
Insurance provider*
Insurance ID/Number*
Additional Information
The State of California - Public Health Department requires that healthcare facilities identify the race and ethnicity of the person(s) they provide medical care to. Please identify your Ethnicity/Race from the selection below. You have the right to refuse to provide this information.
Ethnicity
Race

Patient Information