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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* denotes required field

Patient Information

Hospital location

Due Date

Maternity Doctor

Family Doctor

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

Pediatrician

Note: Pediatrician can be changed at the hospital.

Last Name

First Name

Home Address

City

State

Zip Code

Social Security No.

Check if none

Date of Birth

Place of Birth

State or County

Gender (Legal)

Gender Identity

Sex Assigned at Birth

Sexual Orientation

Home Phone

Alternate Phone

E-mail

Employment Status

Military Status

Military Branch

Occupation

Employer Name

Employer Phone

Employer Address

Religion

Race

Marital Status

Maiden Name

Emergency Contact Information

Contact Name

Relation

Emergency Contact address and phone are the same as the Patient.

Address

City

Phone

Alternate Phone

Contact #2 Name

Relation

Address

City

Phone

Alternate Phone

Insurance Information

No Insurance

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

Insurance Company

Policy ID

Group Number

Insurance Mailing Address

City

State

Zip Code

Check if patient is Primary Insurance Subscriber

Subscriber Last Name

First Name

Birth Date

Relation

Social Security Number

Employer

Employer Address

Insurance Information (continued)

SECONDARY INSURANCE (if NONE, leave fields blank)

Secondary Insurance

Policy ID

Group Number

Mailing Address

City

State

Zip Code

Subscriber Last Name

First Name

Birth Date

Relation

Social Security Number

Employer

Employer Address

Additional Information

Are you a registered Organ Donor?

Yes

I acknowledge I have been informed of the NJ Department of Children and Families partnership with Plan of Safe Care as part the universal drug screening program.

Is there anything else we need to know? (For example, a good time to contact you, if necessary.)

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Maternity Preregistration Form

Form Requirements

Patient Information

Emergency Contact Information

Insurance Information

Insurance Information (continued)

Additional Information