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Maternity Information Form

Welcome to Highland Maternity Center. 

Providing the following information well in advance of your due date, helps to streamline your check in at the hospital so there’s less to worry about when you arrive.  Filling this information out does not admit you to the hospital today.  You will be officially admitted when you arrive at the hospital for your delivery.

It’s best to complete the following information after your 16th week of pregnancy.

Due Date
Is this a Multiple Birth? (twins, triplets,etc):
Is this your first time receiving care at Highland?”:
Maternity Patient Information
Marital Status*:
( ) -
( ) -
Additional Maternity Patient Information
What is your race? Mark one or more races to indicate what you consider yourself to be.*:





What is this your ethnicity? *:
Employment Information Are you currently employed, retired, on disability or a student? *:
Employment Status:
( ) -
Emergency Contact Information Do you have a person to notify in case of an emergency?:
( ) -
( ) -
Do you have an additional emergency contact:
( ) -
( ) -
Your Providers
Insurance Information
Do you have additional insurance coverage?:

Thank you. This information will enable us to better prepare for your admission.

By submitting this form you acknowledge that you can access this link and have been given the information included in “Your Rights as a Hospital Patient in New York State.”

If any of this information changes, you will have the opportunity to update it when you arrive at Highland for your delivery.

For you comfort and convenience, all maternity accommodations at Highland are private rooms. 

*Indicates a required field.