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Methodist Emergency Department

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Pekin Emergency Department

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Proctor Emergency Department

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UnityPoint Clinic - Express (Peoria)

8914 North Knoxville Avenue
Peoria, IL 61615

00 Patients
Waiting Now

UnityPoint Clinic - Express (Washington)

209 North Cummings Lane
Washington, IL 61571

00 Patients
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UnityPoint Clinic First Care - East Peoria

2535 East Washington Street
East Peoria, IL 61611

00 Patients
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UnityPoint Clinic First Care - Peoria Heights

1120 East War Memorial Drive
Peoria Heights, IL 61616

00 Patients
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Birth Care Pre-Registration

Please complete this form at 18-20 weeks in your pregnancy.

Birth *
Delivery Method
Would you like to receive our birthcare information by mail or email?

Patient Information


Marital Status
Race
Translation/Interpreter Services Needed?
Spiritual needs are important to some patients, would you like us to notify your faith community leader of your admission?

Mailing Address


Employment Status (if applicable)

Emergency Contact Information



Mother's Insurance Information



Mother's Secondary Insurance


Secondary Insurance? (If yes, please complete section)

Baby's Insurance Information


Is the baby's insurance the same as the mother/carrier? *

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