Miami Children's Hospital
Local: 305-666-6511
Toll Free: 800-432-6837
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For Patients & Families

Pre-Registration

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

Bold fields are required.

Scheduled Location 




Date of Admission/Diagnostic Testing  (mm/dd/yyyy)
 
Has the patient ever received services at any Miami Children's Hospital Location?

TYPE OF PROCEDURE/TREATMENT/TEST
Please select the applicable category below, then select procedure/treatment/test.  
Laboratory
Pulmonary Care
Enuresis
Ambulatory Services

Radiology













Neuroscience




Heart Station


Rehabilitation Services





Patient's Last Name  
Patient's First Name  
Patient's Middle Initial
Birth Date  (mm/dd/yyyy)
 
Sex  
City, State or Country of Birth
Religion Preference
Phone Number  
Patient Email  
 
Patient Address  
City  
State  
Zip Code  
Referring Physician
(Physician ordering Services)
 
Primary Care Physician (PCP)  
 
PARENT INFORMATION
 
Father's Name
If applicable
Birth Date (mm/dd/yyyy)
 
Phone Number
Is the father's address the same as the patient's address?
Mother's Name
Birth Date (mm/dd/yyyy)
 
Phone Number
Is the mother's address the same as the patient's address?
 
MEDICAID / MEDICARE
 
Does the patient Have Medicaid/Medicare?
 
PRIMARY HEALTH INSURANCE INFORMATION
 
Does the patient Have Health Insurance?
 
SECONDARY HEALTH INSURANCE
Any other medical insurance plan that may provide additional coverage.
 
Does the patient Have Secondary Health Insurance?


Parent/patient (18 years or over) or Legal Guardian must be present to sign required documents.

On your Admission/Registration day, please bring your prescription, Health Insurance card, other Insurance cards and your Credit Card you may be required to pay a 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.