Online Pre-Registration - Broward Health

* Indicates Required Information

Have you been to one of our facilities before?

Yes No

*Please indicate the facility where your appointment is scheduled

If your name has changed since your last visit to our facility,
please enter the name you used

Are you pre-registering for the delivery of your baby?

Yes No

What is your expected due date?

Please enter the name of your OB physician

Non OB-Related Appointments

What is the date of your appointment?

Please enter the name of the procedure listed on your Physician Order

Please enter any associated numeric codes written on the Physician Order

Please enter in your diagnosis

Please enter any associated numeric codes for your diagnosis written on the Physician Order

Name of physician ordering the test

Last name

First name

Phone

Primary care physician information

Last name

First name

Phone

Is your procedure related to an accident?

Yes No

If yes, please identify the nature of your accident

Accident date and time

Accident location (ie. Home, Work, Mall, Store)

State in which accident occurred

Patient name

*Last name

*First name

Middle name

*Email

*Date of birth (mm/dd/yyyy)

Permanent address
*Address 1

Address 2

Apt or Building No.

*City

*State

*Zip

Foreign country

*Phone

Alternate phone

Local address

Check this box if same as permanent address

Address 1

Address 2

City

Zip

State

Phone

Alternate phone

*Marital status

*Gender

*Language

*Religion

*Citizenship(Country)

*Birth place

*Race/Ethnicity

*How did you hear about our facility?

*Best way to contact you

*Best time to contact you

(HH:MM AM/PM)

Would you welcome a visit from your clergy
if you are admitted?

This information indicates who is financially responsible for payment of the account. If the patient is a minor, this section must be completed by the responsible party bringing the patient in for service.

Check this box if the patient is the guarantor (person responsible for the bill)?

Guarantor name

*Last name

*First name

*Home phone

Alternate phone

*Date of birth (mm/dd/yyyy)

Guarantor address

*Address

*City

*State

*Zip

Foreign country

Occupation

*Gender

*Relationship to patient

Check this box if the guarantor is not employed

Employer name

Employer phone

Ext

Employer address 1

Employer address 2

City

State

Zip

Check if the patient has no insurance

Check this box if the patient is the insurance subscriber.

Subscriber/Policy holder information

*Last name

*First name

*Relationship to patient

*Date of birth (mm/dd/yyyy)

Note:Please refer to your insurance card for this information.

*Primary insurance company name

*Effective date of insurance (mm/dd/yyyy)

*Policy No.

*Group No.

Mail insurance claim to:

*Address 1

Address 2

*City

*State

*Zip

*Phone number for customer service
(located on the back of the card)

*Phone number for pre-certification
(located on the back of the card)

Check if you have secondary insurance

Check this box if the patient is the insturance subscriber.

Subscriber/Policy holder information

Last name

First name

Relationship to patient

Date of birth (mm/dd/yyyy)

Be prepared to present insurance card on admission date.
Note:Please refer to your insurance card for this information.

Effective date of insurance (mm/dd/yyyy)

Policy No.

Group No.

Mail insurance claim to

Address 1

Address 2

City

State

Zip

Phone number for customer service
(located on the back of the card)

Phone number for pre-certification
(located on the back of the card)