Maternity Preregistration Form

Form Requirements

This is an exciting time. You're having a baby! Please fill out the following form prior to your admittance to Virtua. Registering before your hospital stay will speed up the admission process on your big day. Before filling out the pre-registration form below, please have the following available:
  • Insurance information (including policy #)
  • Emergency contacts
  • Doctor and Pediatrician info
  • Due date
Please note: all patients will be given a urine drug screening upon admission for delivery.

If you are taking any prescribed medication, or over-the-counter medication, please speak to your Obstetrical provider and take note that you may be referred to the New Jersey Department of Children and Families when your baby is born.
For more information go to:
https://www.nj.gov/dcf/about/divisions/dcsc/Plans-of-Safe-Care-Brochure.pdf

If you are pregnant, the safest choice for your child is to AVOID smoking marijuana. Studies have shown that smoking marijuana while pregnant has been linked to development delays in the child and a higher risk of substance abuse and mental illness later in the in child's life.

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Patient Information

Please choose a location
Please enter a valid date (mm/dd/yyyy)
Please choose a maternity doctor
Note: Please include first and last name of family doctor
Field is required
Note: Pediatrician can be changed at the hospital.
Field is required
Field is required
Please enter your home address
Please enter your city
Please select your state
Please enter a valid zip code
Field is required
Please enter a valid birthdate (mm/dd/yyyy)
Please enter place of birth
Please enter birth state or county
Field is required
Field is required
Field is required
Field is required
Please enter a valid phone
Please enter a valid phone
Invalid Email Format
Please choose an employment status
Please choose an military status
Please choose an military branch
Please enter your occupation
Please enter employer name
Please enter employer phone
Please enter employer address
Please enter your religion
Please enter your race
Please enter your marital status
Please enter maiden name

Emergency Contact Information

Field is required
Please enter your relation with the contact
Please enter your contact's address
Please enter your city
Please enter a valid phone
Please enter a valid alt phone
Field is required
Please enter your relation with the contact
Please enter your contact's address
Please enter your city
Please enter a valid phone
Please enter a valid alt phone

Insurance Information

If you are uninsured, you may qualify for a number of different financial assistance options.
Virtua Financial Counselors are at Virtua Marlton, Mount Holly, and Voorhees hospitals and at Virtua Camden. They can help you determine if you qualify for hospital assistance programs.
They can also help you enroll in Medicaid if you are eligible.
Please call toll free at 1-800-203-3156 for information or assistance from Virtua Financial Counselors.

PRIMARY INSURANCE

Please enter your insurance company
Please enter your policy ID
Please enter your group number
Please enter your insurance mailing address
Please enter your city
Please select your state
Please enter a valid zip code
Field is required
Field is required
Please enter a valid birthdate (mm/dd/yyyy)
Please enter your relation with the subscriber
Please enter subscriber SSN
Please enter the employer name
Please enter your employer's address
Please enter your insurance company
Please enter your policy ID
Please enter your group number
Please enter your insurance mailing address
Please enter your city
Please select your state
Please enter a valid zip code
Field is required
Field is required
Please enter a valid birthdate (mm/dd/yyyy)
Please enter your relation with the subscriber
Please enter subscriber SSN
Please enter the employer name
Please enter your employer's address

Additional Information

Please check this field