• Hospital Pre-Registration Form

  • Please note: This form is for pre-registering for services at Frederick Health Hospital only. Patients with a Frederick Health Medical Group appointment should complete their forms through the Patient Portal.

  • Date of Service/Admission*
     - -
  • Expected Date of Delivery*
     - -
  • Date of Last Menstrual Cycle*
     - -
  • Do you want your primary care provider notified if admitted?*

  • Patient Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Patient Preferred Language

  • Do you need an interpreter?

  • Patient Employment Status

  • Retirement Date*
     - -

  • Additional Patient Information

  • Are you over the age of 18?*
  • Would you like to sign up for the Patient Portal?*
  • Reason for declining Patient Portal

  • Guarantor Information

    A guarantor is anyone, typically parents or legal guardians, who takes financial responsibility for the medical expenses of a patient.
  • Is the guarantor the same as patient?*
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Insurance Information

  • Do you have health insurance?*
  • Subscriber Date of Birth (If Different from Patient)
     - -
  • Do you have secondary insurance?*
  • Subscriber Date of Birth (If Different from Patient)
     - -
  • Is this visit accident related?
  • Date of Accident
     - -
  • Will baby be added to this insurance plan?*
  • Will baby have insurance coverage?*
  • Subscriber Date of Birth (If subscriber is different from patient)*
     - -

  • Pharmacy Information

  • Format: (000) 000-0000.
  • Should be Empty: