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Online Obstetric Pre-Registration
Tallahassee Memorial HealthCare is committed to providing the highest quality medical care possible to all who need and seek our services.  The following pre-registration form will expedite the registration process to make your visit go as smoothly as possible.  

The pre-registration information you submit online is safeguarded by Verisign security certificate and pursuant to legal and regulatory requirements, such as HIPAA, The Health Insurance Portability and Accountability Act.

If you have any questions, please contact Labor and Delivery Registration at (850) 431-0200.


Need Directions? Call (850) 431-0200.

1. Fill Out Form Accurately
When your physician schedules an appointment and you submit this form, our registration office will call you if there are any questions. When filling out the form, please fill out the information as accurately as possible.

2. What to Bring With You
Please be sure to bring the following items with you:

  • Any orders that your physician has given to you
  • Driver's License for ID purposes
  • All of your insurance cards
  • Any co-pay that is applicable to your visit
Have you been a patient at TMH before?    If so, approximately when:

Mommy's
Name:
Address: 
City:
State: ZIP:
Email:
Home Phone: (xxx-xxx-xxxx)
(xxx-xx-xxxx)
Social Security Number:
Due Date:
Date of Birth (mm/dd/yyyy):
Race:
Marital Status:
Religion:
Place of Worship:
Employment Status:  
Employer:
Address:   
City:
State: ZIP:
Occupation:
(xxx-xxx-xxxx)                 
Phone Number: Ext:

Daddy's Name:
Address:
 

City:
State: ZIP:
Home Phone: (xxx-xxx-xxxx)
Cell Phone: (xxx-xxx-xxxx) 
Email:
(xxx-xx-xxxx)

Social Security Number
Date of Birth (mm/dd/yyyy):
Race:

Employment Status:
 
Employer:
Address:   
City:
State: Zip:
Occupation:
(xxx-xxx-xxxx)                 
Phone Number:Ext:

Emergency Contact:    Relationship to Patient:
  Address:        
City:
State: ZIP:
(xxx-xxx-xxxx)
Home Phone:   
(xxx-xxx-xxxx)
Work Phone:     

 Emergency Contact 2:   Relation:
   Address:        
City:
State: ZIP:
(xxx-xxx-xxxx)
 Home Phone:   
(xxx-xxx-xxxx)
Work Phone:   

Complete this section only if Mother is NOT financially responsible
Guarantor:  (person responsible for bill)  
Social Security No:(xxx-xx-xxxx)
  Employer:     (xxx-xxx-xxxx)
Phone:  
  Emp. Address:     City:
State: ZIP: Occupation:  

Please copy the following information from your insurance card
Baby's Insurance:    ID #:    Group #
  Mail Claims Address:

City:
State: ZIP:
(xxx-xxx-xxxx)
Phone Number:   
 Pre Cert. Phone:   
Benefits Phone:   
If your baby will be covered by Medicaid, please notify your caseworker of the upcoming birth.

Mommy's Insurance:    ID #:   Group #
  Mail Claims Address:

City:
State: ZIP:
(xxx-xxx-xxxx)
Phone Number:  
 Pre Cert. Phone:   
Benefits Phone:  

If you do not have insurance or do not have maternity coverage, would you be interested in our Parents Savings Package?  

Mommy's Doctor:  
Baby's Doctor:  

 
 

I have read the Florida Birth-Related Neurological Injury Compensation Association (NICA) brochure entitled "Peace of Mind for An Unexpected Problem." I agree that I have read the brochure and understand that Tallahassee Memorial Hospital participates in this program.

Click the link to read the brochure entitled "Peace of Mind for An Unexpected Problem."

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