Maternity Pre-Registration Form

Please complete the form below to pre-register online to expedite services at the Maternity Place at Broward Health Medical Center and Broward Health Coral Springs.

General Section
Patient Information Section
Emergency Contact Section
Policy Holder's Section
Primary Insurance Section
Secondary Insurance Section
Medicaid Section

If you provide no insurance please contact our offices immediately so that we can make the necessary payment arrangements. If you have any questions regarding your pre-registration, please contact the admitting office at the number shown below:


Broward Health Medical Center

1600 S. Andrews Avenue

Fort Lauderdale, FL 33316



Broward Health Coral Springs

3000 Coral Hills Drive

Coral Springs, Florida 33065

954-344-3000 ext. 327328