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Maternity Pre-Registration Form

We'd like to make your upcoming stay at Palos as pleasant and comfortable as possible. You can help us do that by submitting a Maternity Pre-Registration Form.

Having this information on file will help us avoid delay when it comes time for you to be admitted to the hospital. Please be prepared to present your insurance cards and driver's license. You also will be asked to sign admission consent forms upon your arrival.

* Denotes required fields

Full Legal Name

* Do you speak and understand English?
* Hispanic Ethnicity
* Do You Want Your Pastor to be Notified of Your Admission?
* Do You Wish to Receive Communion During Your Stay?
* Are You Sensitive/Allergic to Latex?

Employment Information

Spouse/Primary Emergency Contact Information

Secondary Emergency Contact

Primary Insurance Information

* Do You Have Insurance That Will Cover This Service?
* Do You Have Secondary Insurance?
Thank you for pre-registering. If any of this information changes or you have questions, please telephone (708) 923-4500.

Should you arrive for admission to the hospital between 6 a.m. and 9 p.m., please enter through the hospital's main entrance.

Should you arrive for admission at night (anytime between 9 p.m. and 6 a.m.), please enter the hospital through the Emergency Department entrance, located on the hospital's east side via the SOUTH DRIVEWAY. You should park in the Emergency parking lot.

All parking at Palos Community Hospital is free.