Admitting Pre-Registration
Expected Admit Date: (M/D/Y)   /   /  Admission to: 
General Admission Information
Admit/Refer Phys:
Diagnosis:
Planned Procedure:
Primary Care Phys:
Primary Phys Phone: (  )  
Maternity Only
Expected Due Date:
Last Menstrual Cycle:
Baby Insurance:
Mom Dr:
Baby Dr:
Patient Information
Patient Name:      
Last                            First                    MI
Patient D.O.B.:
Mailing Address: Addr:
City: State: ZIP:
Primary Phone: (  )  
Work Phone: (  )  
Cell Phone: (  )  
EMail Addr:
Patient SSN:  -  - 
Sex:  Marital Status: 
Emergency Contact Information
Contact Name:      
Last                            First                    MI
Relationship: Relationship of contact to patient:
Primary Phone: (  )  

Work Phone: (  )  
Cell Phone: (  )  
EMail Addr:

Additional Patient Information
Do you have a living will?
Specify your religious affiliation here (optional):
If you would like race included in your patient profile, specify it here (optional):
Have you ever been a VMC patient?
If yes, please select one of the following:
Do you have a Helathcare Power of Attorney?
If you require an interpreter, please select one of the following: Specify if Other:
Insurance Information
Primary Insurance
Provider: Select or specify other ...
Policy Number:
Group Number:
Provider Address: Addr:
City: State: ZIP:
Policy Holder:
Relation to Patient:
Employer:
Holder Date of Birth:
Holder Contact Information
Home Phone: (  )  
Work Phone: (  )  
Cell Phone: (  )  
EMail Addr:
Secondary Insurance
Provider: Select or specify other ...
Policy Number:
Group Number:
Provider Address: Addr:
City: State: ZIP:
Policy Holder:
Relation to Patient:
Employer:
Holder Date of Birth:
Holder Contact Information
Home Phone: (  )  
Work Phone: (  )  
Cell Phone: (  )  
EMail Addr:
Please complete the following pre-admit registration form
as completely as possible to expedite your request.
* Red Indicates
Required Information