Mother’s Worksheet for Child’s Birth Certificate.doc

Mother’s Worksheet for Child’s Birth Certificate FOR HOSPITAL USE ONLY: MOTHER MR# _____________________________ NEWBORN MR# ________________________________ MEDICAID # _______________________________ DELIVERING DR ________________________________ RM # ____________ The information you provide on this worksheet is used to create your child’s birth certificate. The birth certificate is a legal document used to prove your child’s age, citizenship and parentage. Your child will use the birth certificate throughout his/her life. The State of Texas safeguards against the unauthorized release of identifying information from birth certificates to protect the confidentiality of parents and their child. Please PRINT or TYPE your responses carefully and accurately as errors are difficult and expensive to correct. There are drop down boxes as well as selection boxes. Be sure to move your cursor over each field to select. CHILD’S PLACE OF BIRTH Name of Hospital or Location Address State Nativiti Women’s Health Birth Center 26614 Oak Ridge Drive Texas County City Zip Code Montgomery The Woodlands 77380 CHILD’S INFORMATION Time of Birth AM / PM Date of Birth Plurality (please select one) Birth Order (please select one) Number of Infants Born Alive at this Birth? (please select one) MOTHER’S CURRENT LEGAL NAME First Name Middle Name Last Name Suffix CHILD’S LEGAL NAME First Name