Birthplace Pre-Registration Form

You will need the following to complete this form:

• Your Social Security Number (SSN)
• Your OB's office contact information
• Your insurance information

Please Note: Mercy Birthplace & NICU will receive the information you enter on this form. By providing your email address, you agree to receive emails from Mercy. Your healthcare treatment and services are not conditioned upon your consent to receive emails. You can opt out of receiving emails from Mercy by clicking unsubscribe at the bottom of email messages or by contacting Mercy Marketing at 319-398-6086 or Mercy Medical Center - Attention: Marketing, 701 10th Street SE Cedar Rapids, IA 52403.