Pre-Register For Your Delivery

Preregister for your delivery at Evanston or Highland Park Hospital up to 90 days before your due date. You'll need:

Your (or the insured's) insurance information, including group name and number
Full contact information for your spouse or designated emergency contact

Items marked with an asterisk (*) are required. This is a secure form.

Please note that the NorthShore policy does not permit videotaping/still photography during delivery. You may take pictures/videos before and after the birth of your baby.

Mother's Information

Mother's Name*

Address*

City*

State*

ZIP Code*

Phone - Day*

Email*

Date of Birth*
(mm/dd/yyyy)

Do you have a living will?*

Race

Marital Status*

Employment Status*
Occupation
Employer's Name
Employer's Address
Employer's City
Employer's State
Employer's ZIP Code
Employer's Phone - Day

Do you have a spouse?*

Spouse's Information

Same as my address

Spouse's Name*

Address*

City

State

ZIP Code

Phone - Day*

Date of Birth*
(mm/dd/yyyy)

Spouse's Employment*
Spouse's Occupation
Employer's Name
Employer's Address
Employer's City
Employer's State
Employer's ZIP Code
Employer's Phone - Day

They're my emergency contact

Emergency Contact's Information

Relationship to your emergency contact?*

Contact's Name*

Address*

City*

State*

ZIP Code*

Phone - Day*

Your registration will not be submitted until you click "Submit My Preregistration" at the bottom of the page.

Please take a moment to review the information you provided in the previous screens. Need to make changes?

Mother's Information

Mother's Employment Information

Spouse's Information

Spouse's Employment Information

Emergency Contact's Information

Insurance Information

Hospital Information

Religious Preferences

Please select your hospital.*
Expected delivery* (mm/dd/yyyy)	On or before
Number of Children Expected
Name of OB Doctor or Certified Nurse Midwife*	Physician Certified Nurse Midwife
Name of Pediatrician*

Insurance Carrier*	Send copies to hospital
Group Name*
Group Number*
Effective Date*
Subscriber Name*
Subscriber ID*
Subscriber's Social Security Number*
What is your relationship to the insured?*
Insurance Carrier Address
City
State
ZIP Code
Insurance Carrier Phone - Day

Our Hospitals

Outpatient Clinics

Specialty Care

Primary Care

What's Next in Healthcare

Patient & Visitor Information

Maternity Preregistration

Mother's Information

Spouse's Information

Emergency Contact's Information

Specific Information

Religious Preferences