Childbirth Registration

There are two steps to complete in order to preregister for your childbirth at a Houston Methodist Childbirth Center.

  1. Complete the form below. Once you submit this form, a representative will contact you within three business days if additional information is needed. If your delivery is scheduled to occur within the next 24 hours, please contact us at the scheduling office for your location.
  2. Sign your consent forms. You have a choice in how you want to sign your documents. This can be done in-person or at some facilities, by electronic docu-sign.
Hospital Location
Hospital location for procedure *
Patient Information
First name *
Middle name
Last name *
Country *
Address *
Apartment/Unit
City *
State *
State
Postal code *
City Code *
Country Code *
Primary phone number *
Email *
Confirm email *
Preferred way we contact you *
Date of birth *
Social security number
Race
Ethnicity
Needs interpreter *
What is the language you need for interpretation? *
Primary care doctor name *
  • Please include doctor's address, cross streets, and/or phone number.
  • This is not your Obstetrics doctor. If you do not have a Primary Care doctor, please write 'None.'
Religion
Marital status *
Identification: To speed up your registration, please upload your valid Identification (driver's license, state or military issued identification or valid passport.) Upload a photo (jpg/jpeg, png) or pdf file smaller than 4 MB.
Your Information
Are you the patient?
Your name *
Country *
Your phone number *
Is your address the same as the patient?
Your address *
City*
State *
State
Postal code *
City code *
Country code *
Your email address
Confirm email address
Your relationship to the patient *
Emergency Contact Information
Emergency contact name *
Emergency contact phone number *
Relationship to the patient *
Alternate contact name
Alternate contact phone number
Alternate contact relationship to the patient
Employment Information
Employment status
Employer name
Insurance Information
Do you have insurance? *
Health insurance plan name *
Health insurance type *
Member ID number *
Group number
Insurance's customer service phone number
Insurance Card: To speed up your registration, if available, please upload a photo (jpg/jpeg, png) or pdf document of BOTH sides of your insurance card. Uploaded files must be smaller than 4 MB.
Is the patient the subscriber? (The subscriber is the policy holder; the person whose employer provides the insurance you are using.) *
Name of the subscriber *
Relationship to the patient *
Subscriber date of birth *
Subscriber's employer name*
Medical recipient number *
Name on Medicare card *
Medicare number *
Part A effective date *
Part B effective date
Do you have secondary insurance coverage? (Insurance 2) *
Secondary insurance plan name *
Health insurance type *
Member ID number *
Group number
Insurance's customer service phone number
Insurance Card: To speed up your registration, if available, please upload a photo (jpg/jpeg, png) or pdf document of BOTH sides of your insurance card. Uploaded files must be smaller than 4 MB.
Is the patient the subscriber? (The subscriber is the policy holder; the person whose employer provides the insurance you are using.) *
Name of the subscriber *
Relationship to the patient *
Subscriber date of birth *
Subscriber's employer name*
Medical recipient number *
Name on Medicare card *
Medicare number *
Part A effective date *
Part B effective date
Are you a self-paying patient? *
Do you have health insurance? *
If yes, what is the name of your insurance? *
Have you notified your insurance of this procedure? *
Procedure Details
OB/GYN name *
OB/GYN phone number *
Due date*
What type of delivery are you planning? *
Are you a gestational (surrogate) carrier? *
Last menstrual cycle*
Are you having twins, triplets, etc.? *
What is your preferred local pharmacy? (include address and/or cross streets)
What is the name of the insurance you anticipate adding your baby to, if applicable?
Do you currently have a Texas Advanced Directive you would like to put on file with Houston Methodist? Example forms include: Medical power of attorney, DNR (Do not resuscitate), and Directive to Physicians and Family.
If you are able, please upload your Advanced Directive document(s) as a photo (jpg/jpeg, png) or pdf file type. The uploaded file must be smaller than 4 MB.
Would you like to participate in a program with Houston Methodist and the Texas Department of State Health Services (DSHS) (called ImmTrac2) in which both organizations bi-directionally share immunization information? *
Click to learn the Benefits of Participating in the Texas Immunization Registry.
I would like to stay connected with Houston Methodist on upcoming events, health tips and newsletters.
Authentication *