BIRTH CERTIFICATE INFORMATION SHEET CONGRATULATIONS ON THE BIRTH OF YOUR CHILD PLEASE READ CAREFULLY BEFORE COMPLETING
Provide for you is a birth certificate worksheet (attached). The information obtained will be used to produce a “Certificate of Live Birth” that will serve as a birth record. A Birth Record is a statement of facts concerning an individual. It is a permanent legal document. It is the responsibility of the parent to give accurate information. DO NOT ABBREVIATE OR USE INITIALS. After the worksheet is given to the hospital staff, a “Record of Live Birth” will be printed. A parent must sign the typed certificate before being discharged (not this sheet). You will not receive the original birth certificate at the hospital. It is the parent’s responsibility to send the form to receive the baby’s actual birth certificate. If mother is single at time of birth, an Affidavit Acknowledging Paternity is available for your convenience. An Affidavit Acknowledging Paternity is a form that gives the single mother and natural father a voluntary opportunity to acknowledge paternity. If the form is used, A) the mother consents to an assertion of paternity by the father, B) the father states that he is the natural father of the child. The natural father must be present and able to show a picture I.D. If these requirements cannot be met, the father’s name will not be able to go on the birth certificate. If the mother is married at the time of birth and the natural father of the baby is not the husband, by Oklahoma State Law the husband must be listed on the birth certificate. Lakeside Women’s Hospital follows the guidelines set forth by the State of Oklahoma and will not bend regarding this law. After discharge, the mother and natural father will need to follow up with the Department of Vital Records to get the paternity changed. If you have any questions regarding this, you will need to call the Vital Statistics Department at 405-271-4040. If you check yes to receive your child’s social security care, please realize that it takes 13-16 weeks to receive the card at your home address. Once you have initialed and signed the “Certificate of Live Birth”, the hospital is not responsible for the social security number. If you have not received it by the 16th week, please call the Social Security Administration at 800-7721213.
DO NOT LEAVE WITHOUT SIGNING TYPED COMPLIMENTARY BIRTH CERTIFICATE
Parent Form **PLEASE DO NOT ABBREVIATE OR USE INITIALS/USE YOUR LEGAL NAME**
CHILD INFORMATION Last Name: Birth Date: ________Time: First: AM or PM Sex: ___ Middle: Gestational age:______________________ Length:_______________________
Doctor who delivered baby:
Weight:________lbs.__________oz.
If other than doctor, Name of Person who deliver:____________________________________ Apgars:_______ ________________ Do you wish to sign up for your child s Social Security Number now? MOTHER INFORMATION Last Name: Maiden Name: Birthplace State: Mailing Address: County: Race: Highest Grade Completed (1-12 grade) Number of live births (do not count this one) Number of miscarriages and/or terminations: Month prenatal care began (first, second, third, etc.) Tobacco use during pregnancy? Alcohol use during pregnancy? Mother s Weight Gain: Were you married at time of conception or birth? Yes Yes Are you within city limits: Of Hispanic Origin Y N Specify: ______________ Now deceased _______ First: Birth Date: Current Residence State: City: SS#: Phone_______________________ Zip Code: Middle: _____________________
How many years of College (1-5 years) Date of last birth: Date of last termination/or miscarriage:
Number of Visits________Date of last period:
No Average number per day No Average drinks per week:
If No please fill out following page. If Yes
FATHER INFORMATION
disreguard following page.
Last Name: Birth Date: Mailing Address:
Suffix: I, II, III, JR. SR. Birthplace State:
First:
____ Middle:
______________ ______________ Zip Code:
___City______________County___________ SS#: City:
Phone_______________________County: Race: Highest Grade Completed (1-12 grade) Of Hispanic Origin Y N Specify: ______________
How many years of College (1-5 years) OTHER INFORMATION
Was mother s blood tested for syphilis? Was prophylactic drug used in baby s eyes? Method of Delivery: Vaginal
Yes Yes
No Date: No Was newborn screened for PKU? Primary C-Section Repeat C-Section Yes No Forceps Vacuum
Vag after C-Section
Mother s or Father s Signature:
DO NOT LEAVE WITHOUT SIGNING TYPED COMPLIMENTARY BIRTH CERTIFICATE
Please fill this page out if you answered NO the following question (were you married at time of conception or birth?) Mother’s Information
American Indian? Yes______No______ Enrolled? Yes_____No_____ What Tribe(s)?________________________________ Mother s Employer_____________________________________________________________ Address of Employer___________________________________________________________ Mother s Insurance Carrier_______________________________________________________ Policy Type______________________Policy Number_________________________________
Father’s Information
American Indian? Yes______No______ Enrolled? Yes_____No_____ What Tribe(s)?________________________________
Father s Employer____________________________________________________________ Address of Employer__________________________________________________________ Father s Insurance Carrier______________________________________________________ Policy Type________________________Policy Number______________________________
_____________________________________________________________________
DO NOT LEAVE WITHOUT SIGNING TYPED COMPLIMENTARY BIRTH CERTIFICATE
PLEASE REMEMBER THAT BIRTH CERTIFICATES ARE A LEGAL DOCUMENT!!!!! SO PLEASE USE YOUR LEGAL NAME AS IT APPEARS ON YOUR DRIVERS LICENSE. DO NOT ABBREVIATE OR USE INITIALS!!!!!
DO NOT LEAVE WITHOUT SIGNING TYPED COMPLIMENTARY BIRTH CERTIFICATE