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Labor & Delivery

Labor & Delivery Pre-Registration Form

Pregnancy & Parenting E-Newsletter

Receive our weekly parenting e-mail tailored to your personal week of pregnancy and then the age of your newborn through your baby's first year of life.

Labor & Delivery Pre-Registration Form

Please note your insurance plan may require a co-payment, co-insurance or deductible. Your payment will be requested at the time of your visit. Rex Healthcare accepts cash, personal checks and most major credit cards.

* Denotes required fields

General Information

* Expected Due or Delivery Date (mm/dd/yyyy)

* Type of birth

Newborn physician

Race of Newborn

Ethnicity of Newborn

Expectant Mother's Information

Patient's Legal Name

(Please enter the legal name listed on your driver’s license or state-issued identification card)

* First Name

* Middle Name

* Last Name

* Maiden Name

* Last 4 Digits of SSN

* Birth Date

* Race

* Ethnicity

* Marital Status

* Address

* City

* State Example: NY

* ZIP Code Example: 12345

* County

Country

* Email

I'd like to subscribe to the free UNC REX Pregnancy and Parenting E-Newsletter.

* Primary Phone Example: 123-123-1234 x123

Secondary Phone Example: 123-123-1234 x123

* Primary Spoken Language

* Religious Denomination

Employer's Information

* Employment Status

Emergency Contact Information

* Emergency Contact's First Name

* Emergency Contact's Last Name

* Relation to Patient

* Address

* City

* State Example: NY

* ZIP Code Example: 12345

* Primary Phone Example: 123-123-1234 x123

Secondary Phone Example: 123-123-1234 x123

General Care Information

* Admitting/Referring Physician

* Primary Care Physician

Sign Up For Classes

Explore our catalog of classes designed to help you with all aspects of pregnancy, delivery and returning to life at home. Register for a class today!

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