Medstar Harbor Hospital

Pre-Registration

If you're scheduled to have diagnostic services at Medstar Harbor Hospital, pre-register today. Simply fill out the form below to give you peace of mind when you arrive at the hospital. For additional information regarding your registration, please call 410-350-3274.

* required information

Patient Information
Last Name* First Name* Middle Name
DOB* / / SSN* - - Phone* - -
Race Please specify "other" here.
Ethnicity Religion
Address*
City* State*     Zip*  County*
Marital Status* Please specify "other" here. Maiden Name
Referring Physician* Referring Physician Phone* - - Test Date* / /
Primary Care Physician* PCP Phone* - -
Employer Information
Work Status*    Please specify "other" here. Occupation*
Patient's Employer*    Work Phone*  - -    Ext. 
Address*
City*    State*     Zip* 
Relative Information
Spouse or Nearest Relative* Relationship to Patient*
Address*
City*    State*     Zip* 
Phone Numbers of Spouse or Nearest Relative listed above
Phone* - -            Alternate Phone - - *
Insurance Information
Insurance Company* Policy Number*
Group Number* Medical Assistance Number
Address of Insurance Company*
City*    State*     Zip* 
Insurance Phone* - -
Policyholder Name* Policyholder DOB* / /
Policyholder SSN* - - Policyholder Employer*
Address*
City*    State*     Zip* 
Policyholder Phone* - -