Hospital Pre-Registration

The Bethesda Center for Women and Children knows moms-to-be have a lot to do! For your convenience, you can pre-register for your delivery today!

Simply fill out the form below OR click here to print out and complete the Maternity Pre-Registration FormThen mail or fax the completed form to:

Bethesda Hospital East
Attn: Admitting Department
2815 South Seacrest Boulevard
Boynton Beach, FL 33435
Fax: 561.736.7263

If you have any questions, please call the Admitting Department at 561.737.7733, ext. 84636. Their normal business hours are Monday through Friday, 9:00 a.m. to 5:30 p.m.

 


Maternity Pre-Registration Online Form

*Please complete the form in its entirety. Thank you.

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Marital Status
Race
Ethnicity
If so please enter email address above.

Insurance

If you have insurance that you’d like us to bill for you, please provide the following:
If other than the patient
If yes, please provide the name of the employer
If you do not have insurance, please contact us at (561) 737-7733, ext. 84427. We will assist you with making financial arrangements.

Maternity Information

Florida law requires that we inquire about Advance Directives. Do you have a living will?
Do you have a health care surrogate?
If you would like information regarding Florida Advance Directives, please call us at (561) 737-7733, ext. 84427. We will send information to your home.
Are you an organ donor?
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NICA Acknowledgement

NICA NOTICE TO OBSTETRIC PATIENT

I have been furnished information by Bethesda Hospital and received a brochure entitled, “Peace of Mind for an Unexpected Problem” prepared by Florida’s Birth Related Neurological Injury Compensation Association (NICA) and pursuant to Section 766.316, Florida Statutes, have been advised of this hospital’s participation and, on behalf of the physicians and midwives who are employed by or working with “Ob Hospitalist Group, LLC,” Bethesda Health Physician Group (BHPG), and other obstetrical groups and their physicians and midwives of which I have been made aware, that are or may participate in that program, wherein certain limited compensation is available in the event certain types of qualifying neurological injuries may occur during my labor, delivery or resuscitation efforts at Bethesda. For specifics on the program, I understand I can contact the Florida Birth-Related Neurological Injury Compensation Association, Post Office Box 14567, Tallahassee, Florida 32317-4567, (800) 398-2129. I specifically acknowledge that I have received a copy of the Brochure prepared by NICA.

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