HCMC - Prenatal Center Tours and Classes

HCMC Prenatal Classes Registration Form
(Fill out 1 form per class)

First Name
Last Name
Address
City
State
Zip Code
Home Phone
Work Phone
E-mail
Birthdate
Medical Record Number
For your prenatal care who do you see?
Your Clinic Name
Is this your first baby?	Yes No
Due Date
Prenatal Class Name desired	Looking for Infant and Child CPR? Register here.
Prenatal Class date desired
Insurance Company*
	*We bill insurance for the cost of the class. If you are NOT planning to deliver at Hennepin, you will need to register as a patient. Please call 612-873-2722 to register. If you do not want us to bill your insurance, please bring cash, money order, or check (payable to Hennepin County Medical Center) to the class.
Thank you for completing this form!