Vidant Health | Eastern NC Health Care | Find a Doctor



We are so excited you decided to have you baby at a Vidant Health Hospital. Thank you for allowing us to care for you and your family during this special event. Please complete this registration form prior to your 24th week of pregnancy and return via mail or fax as noted above. We look forward to seeing you!Estimated Due Date ________________________ Hospital delivering your baby _____________________________Last Name ______________________ First name _______________________ Middle/Maiden___________________Date of Birth _______________ SSN _________________________ Marital Status: Single/Married/Divorced/WidowedMailing Address______________________________________ City/State/Zip __________________________________Physical Address ____________________________________ City/State/Zip ___________________________________Home phone # ______________________ Cell phone # ___________________ Work phone # ____________________E-mail address _________________________________________________ Race _________________________Ethnic Group: Non-Hispanic/Hispanic/Other Preferred/Primary Language ___________ Need Interpreter: Yes/No Employment Status: Full-time/Part-time/Retired/Self-Employed/Disabled/Active military/Student/Minor/Not EmployedEmployer ______________________________________________________ Occupation_______________________Emergency contact name ___________________ Relationship __________________ Phone #___________________Do you have an Advanced Directive or Living Will? Yes/No, if yes please provide us with a copyDo you have a Financial and or Medical Power of Attorney? Yes/No, if yes please provide us with a copyMaternity InformationDate of Last Menstrual Period ______________________________ Are you expecting multiple babies, Yes/NoObstetric Provider _______________________________ Obstetric Provider Phone # ___________________________Primary Care Provider ___________________________ Primary Care Provider Phone # _________________________Please turn over to complete and sign the back of this formInsurance Information – please provide copies of your insurance card/cardsPrimary Insurance company _____________________________________________________________________Subscriber’s name ________________________________________ Subscriber’s date of birth ______________Policy # __________________________ Group # ___________________ Relationship to patient _____________Secondary Insurance company ___________________________________________________________________Subscriber’s name ________________________________________ Subscriber’s date of birth ______________Policy # ___________________________Group # ____________________ Relationship to patient ___________The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly tothe physician. I understand that I am financially responsible for any balance. I also authorize payment of all medical benefits which are payable to me under the terms of my insurance policy to be paid directly to the above named physician for services rendered.Signature of patient/guardian_________________________________ Date ______________ Time_________ ................
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