Labor and Delivery Pre-Admission Form

En Español
 

You are about to use the Lucile Packard Children's Hospital Labor and Delivery maternity online pre-registration tool. This form must be filled out at least 1 month before your due date. All required fields are marked with a red asterisk (*). We will contact you if we have any questions and to verify your registration. If you have any questions, please call (650) 497-8229.

Before you begin the form, please turn pop-up blockers off, or add this site as an exception. The form will take 20-30 minutes to complete and you will be asked about the following information:
  • Mother's information, including employment
  • Father's/domestic partner's information, including employment
  • Pregnancy information, including due date and desired method of delivery
  • Emergency contact. This can be the father/domestic partner.
Mail or fax the following forms:
  • Insurance information (we require copies of the front and back of your insurance card)
  • Copy of any photo ID
  • Advance Health Care Directive Information Form, and a copy of your advance health care directive (if you have one)
  • Terms and Conditions of service form (2 pages), for the mother, where we will require one signature on page 2
  • Terms and Conditions of service form (2 pages), for each unborn child you are expecting, where we will require two signatures on page 2
  • Notice of Privacy Practices acknowledgment receipt form
All forms may be sent to us by:
  • Fax: (650) 725-3574 or
  • Mail to:
    • Lucile Packard Children's Hospital
    • 725 Welch Road 1st floor
    • Mail Code: 5923
    • Palo Alto, CA 94304