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/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

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/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9])$?)\s*(?:[.-]\s*)?([2-9]\d{2})\s*(?:[.-]\s*)?(\d{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

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Pavilion for Women Hospital Admissions Pre Registration Form / / Formulario de Registro Previo al ingreso al Pavilion for Women Hospital

M-D-Y

Warning: DOB can't be a future date. Please re-enter DOB

Single / Soltero

Married / Casado

Divorced / Divorciado

Separated / Separado

Widowed / Viudo

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English

Spanish

Vietnamese

Arabic

Chinese

Tagalog

Other

Yes / Si

No / No

reset

Yes / Si

No / No

reset

C-Section / Cesárea

Vaginal Delivery / Parto Vaginal

Surgery / Cirugía

M-D-Y

Warning: Expected Date of Delivery can't be a past date. Please re-enter Expected Date of Delivery/ Advertencia: La fecha de entrega esperada no puede ser una fecha pasada. Vuelva a ingresar la fecha de entrega esperada

M-D-Y

Warning: Surgery Date can't be a past date. Please re-enter Surgery Date / Advertencia: la fecha de la cirugía no puede ser una fecha pasada. Por favor, vuelva a ingresar la fecha de la cirugía

Adoption / Adopción

Surrogacy / Subrogación

Self Pay / Paga por su cuenta

Insured / Asegurado

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Self / Mismo

Spouse / Cónyuge

Child / Hijo(a)

Other / Otro

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M-D-Y

Note: Please attach copy of primary insurance card below. Please include front and back of card / Por favor incluya a continuación una copia de la tarjeta del seguro primario. Por favor incluya el frente y reverso de la tarjeta.

Yes / Si

No / No

reset

Self / Mismo

Spouse / Cónyuge

Child / Hijo(a)

Other / Otro

reset

M-D-Y

Note: Please attach copy of secondary insurance card below. Please include front and back of card / Por favor incluya a continuación una copia de la tarjeta del seguro secundario. Por favor incluya el frente y reverso de la tarjeta.

Spouse / Cónyuge

Child / Hijo(a)

Other / Otro

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*The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Texas Children's Hospital and my insurance company to release any information required to process my claims. / La información anterior es verdadera según mi conocimiento. Yo autorizo a que mis beneficios del seguro médico sean pagados directamente al médico. Entiendo que soy financieramente responsable de cualquier saldo. También autorizo a Texas Children's Hospital y a mi compañía de seguros a que divulguen toda la información necesaria para procesar mis reclamos.

* must provide value

Agree / Acuerdo

M-D-Y

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Thank you for choosing Texas Children's Hospital. Please complete the form in its entirety. Incomplete forms will not be processed. Upon submission, a printable view of the completed hospital pre-admission registration form will be available for download / Gracias por escoger Texas Children's Hospital. Por favor complete el formulario en su totalidad. No se procesarán solicitudes incompletas. Al enviar el formulario, una copia del formulario de registro previo al ingreso al hospital estará disponible para descargar.

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