Maternity Registration Form
If you can not submit this form (for any reason, technical issues, mandatory fields, etc.) please call 908-788-6167 between the hours of 8:00 AM - 8:00 PM M-F or 8:00 AM to 4:00 PM on Saturday.

Remember, you need to enroll your child in your health insurance plan within 30 days of his/her birth. Also, please note, if your newborn will not be covered under the same insurance as you, please let us know what insurance the baby will have so that we can bill appropriately and you will not be left with any billing issues.
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Email *
Who is completing the form?                                             *
If other than the patient, please enter your full name.
PATIENT INFORMATION:
First Name: *
Last Name: *
Email Address: *
Phone Number: *
Have you ever been a patient with Hunterdon Medical Center? *
Have you ever delivered an infant at HMC before?
Number of live births? (other than this pregnancy)
If other selected, what is the number of living children?
Maiden Name/Name at Birth:
First name on Driver's License or Passport: *
Last name on Driver's License or Passport: *
Date of Birth: *
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/
YYYY
Social Security Number:
Approximate Due Date: *
MM
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DD
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Name of Delivering Practice: *
If "Other" was selected for your delivering practice, please specify the practice name below:
Primary Care Office/Provider
The practice/provider you see for routine care when you are not pregnant. (ie: physicals, sick visits, immunizations, etc.)
Name of primary care office for patient:
Name of primary care provider for patient:
Infant primary care provider (name of pediatrician for follow-up care): *
Marital Status: *
Race: *
Hispanic Origin/ Ethnicity *
Sexual Orientation *
Additional Sexual Orientation Information
Gender Identification *
Religious Preferences:
Did you serve in the Military?
Clear selection
Advance Directive:
Defined as a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor.
Do you have an Advance Directive?                                   *
If you have an Advance Directive, where can it be found? (ie: at home, in my safe, etc.)
Primary Language: *
If other language, please specify:
Need Interpreter: *
Patient Address 1: *
Patient Address 2:
Patient City: *
Patient State: *
Zip code: *
Patient township/borough of residence? (ie: township/borough/municipality where your property taxes are paid) *
Patient Phone *
Phone Type *
Patient Secondary Phone:
NEXT OF KIN/EMERGENCY CONTACT
Next of Kin/Emergency Contact First Name: *
Next of Kin/Emergency Contact Last  Name: *
Next of Kin/Emergency Contact Relationship: *
If other selected, describe your Next of Kin/Emergency Contact relationship:
Next of Kin/Emergency Contact Address 1:
Next of Kin/Emergency Contact Address 2:
Next of Kin/Emergency Contact City:
Next of Kin/Emergency Contact State:
Next of Kin/Emergency Contact Zip:
Next of Kin/Emergency Contact Cell Phone: *
PATIENT EMPLOYMENT
Patient Employment Status: *
Patient Name of Employer: *
(if not employed please type none)
Patient Occupation: *
(if not employed please type none)
PRIMARY INSURER INFORMATION
The Primary Insurer is the policy owner, or the person who carries the insurance, or the subscriber to the insurance (ie: Patient, Spouse, Patient Parent.)
Primary Insurer Information First Name: *
(If no insurance, please type none)
Primary Insurer Information Last Name: *
(If no insurance, please type none)
Primary Insurer's Employer: *
(If no insurance, please type none)
Primary Insurer Information DOB:
MM
/
DD
/
YYYY
Primary Insurer Information Relationship:
Clear selection
If other than the patient, please enter Social Security Number of primary insurer:
Primary Insurance Type: *
Primary Insurer Information Name of Insurance Company: *
If other, please specify the name of your primary insurance company:
Primary Insurer Information Policy Number/ ID #:
Primary Insurance Group #:
Primary Insurer Information Address 1:
Primary Insurer Information Address 2:
Primary Insurer Information City:
Primary Insurer Information State:
Primary Insurer Information Zip:
Primary Insurer Information Home Phone:
Primary Insurer Information Cell Phone:
Primary Insurer Information Work Phone:
SECONDARY INSURER INFORMATION
If the patient has Secondary Insurance, the secondary insurer is the policy owner, subscriber or the person who carries the secondary insurance.
Secondary Insurer Information First Name:
Secondary Insurer Information Last Name:
Secondary Insurer Information DOB:
MM
/
DD
/
YYYY
Secondary Insurer Information Social Security Number:
Secondary Insurer Information Relationship:
Secondary Insurance Type:
Clear selection
Secondary Insurer Information Insurance Company:
Secondary Insurer Information Policy Number:
Secondary Insurance ID#:
Secondary Insurance Group #:
Secondary Insurer Information Street Address 1:
Secondary Insurer Information Street Address 2:
Secondary Insurer Information City:
Secondary Insurer Information State:
Secondary Insurer Information Zip:
Secondary Insurer Information Home Phone:
Secondary Insurer Information Work Phone:
Secondary Insurer Information Cell Phone:
Infant Insurance at Discharge*
*Remember you need to enroll your child in your health insurance plan within 30 days of his/her birth. Also, please note if your newborn will not be covered under the same insurance as you. Please let us know what insurance the baby will have so that we can bill appropriately and you will not be left with any billing issues.
Clear selection
If other was selected, please specify infant insurance at discharge:
Comments:
Were there any fields in this form that you want or need to supply additional information?
Any additional questions or concerns you would like us to contact you regarding?
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