Please complete the form in full. Click on the tabs at the top to move through individual sections of this form. Upon receipt of your completed pre-registration form, we will mail you confirmation and further information to assist you in preparing for your stay at Kapi'olani. We look forward to delivering your little miracle.

Patient
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Patient Information


Your Information
First Name * Last Name *  
 
     
Social Security Number Birth Date (m/d/yy) *  
 
     
Marital Status *    
     
Maiden Name (required if married) Ethnicity  
 
     
Religion Gender  
 
     
 Email    
 

Delivery Information
Your Expected Date of Delivery (m/d/yy) *
 
* Have you ever received services at Kapiolani Medical Center for Women & Children?
If yes what name were you registered under 

Advance Directive
* Do you have an advance directive? (If yes, must be brought upon admission)

Patient Residence Address
Street Address * City * State * Zip *

Patient Mailing Address (if different from above)
Street Address City State Zip

Patient Telephone Numbers
Type Phone Number
Home
Work
Cellular
Pager

Patient Employer
Employer Name      
       
Employer Street Address City State Zip
     
       
Phone Number Occupation
       
Employment Status
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