Haymarket Medical Center

Online pre-registration

*Reason for visit:  
*Visit is related to:  
*Date of appointment:  
*Ordering Physician Name:  
*Primary Care physician:  
*First Name:  
*Full Middle Name:  
*Last Name:  
Maiden Name (if applicable):
*For security purposes, please provide your mother's maiden name:  
*Marital Status:  
*Birth Date:  
*Social Security No.:  
*Street Address:  
*Zip Code:  
*Home Phone No.:  
Work Phone Number:
*Email Address:  
*What is your preferred language:  
*Ciy and state where you were born:  (Outside of US may be selected)    
*Religion affiliation/preference:  
If you would like to authorize the clinical staff to discuss your medical treatment with anyone during your hospital visit, please provide us with the full name of the person:
If admitted to the hospital, would you like to have your name listed in the following?
*Religion Directory (for clergy visitation):  
*Patient Visitation Directory: