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:

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

Note: Please include first and last name of family doctor.

Note: Pediatrician can be changed at the hospital.

Emergency Contact Information

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.


Insurance Information (continued)

SECONDARY INSURANCE (if NONE, leave fields blank)

Additional Information