If you have any questions concerning the completion of this form, please call 305-662-8260 OR 305-663-8413.

Bold fields are required.

Date of Admission/Diagnostic Testing	(mm/dd/yyyy)
Has the patient ever received Hospital services?	YesNo
Type of Procedure/Treatment/Test
Patient's Last Name
Patient's First Name
Patient's Middle Initial
Birth Date	(mm/dd/yyyy)
Sex	MaleFemale
City, State or Country of Birth
Religion Preference
Social Security Number If unknown, please enter nine (9) zeros	(123-45-6789)
Phone Number
Patient Email
Patient Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
Patient Employer
Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
Phone Number
Attending Physician (Physician ordering Services)
Referring Physician
Primary Care Physician (PCP)
PARENT INFORMATION
Father's Name If applicable
Click here if address is the same as Patient's Address.
Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
Phone Number
Birth Date	(mm/dd/yyyy)
Social Security Number If unknown, please enter nine (9) zeros	(123-45-6789)
Employer
Mother's Name
Click here if address is the same as Patient's Address.
Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
Phone Number
Birth Date	(mm/dd/yyyy)
Social Security Number If unknown, please enter nine (9) zeros	(123-45-6789)
Employer
EMERGENCY CONTACT INFORMATION
Name
Relationship to Patient
Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
Phone Number
PRIMARY HEALTH INSURANCE INFORMATION
Check here if you DO NOT HAVE HEALTH INSURANCE or if you have MEDICAID / MEDICARE. (Please click here to go skip Health Insurance Section)
Check here if you DO HAVE HEALTH INSURANCE. If you do, please fill the insurance fields below.
YOUR INSURANCE CARD WILL BE SCANNED AT TIME OF REGISTRATION. The insurance company that covers the patient through an employer, group health plan or private policy.
Name of Insurance Company
ID Number
Employer Group Number
Group Name
Authorization/Referral Number
Social Security Number If unknown, please enter nine (9) zeros
Subscriber Last Name
Subscriber First Name
Relationship to Patient
Insurance Company Phone Number
Claims Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
MEDICAID / MEDICARE
Medicaid ID Number
Medicare ID Number
SECONDARY HEALTH INSURANCE Any other medical insurance plan that may provide additional coverage.
Name of Insurance Company
ID Number
Employer Group Number
Group Name
Authorization/Referral Number
Social Security Number If unknown, please enter nine (9) zeros
Subscriber Last Name
Subscriber First Name
Relationship to Patient
Insurance Company Phone Number
Claims Address
City
State	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Islands Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory
Zip Code
ACCIDENT
Are these services the result of a car accident?	YesNo
Type of accident
What is the date of the accident?	(mm/dd/yyyy)
Name of the Insurance Company
Phone Number
Claim Number
Parent/patient (18 years or over) or Legal Guardian must be present to sign required documents. On your Admission/Registration day, please bring your Health Insurance card, other Insurance cards and your Credit Card and be prepared to pay deductible, co-pay, payment or deposit if applicable. Deposits/Co-payments: Deposits/CO-payments are determined by your insurance company and based on specific plan benefits. For most services, the co-payment will be listed on your insurance card. CO-payments/Patients portions are due at the time of service.