• Patient Registration Form

  • Patient Information

  • Gender
  • Date Of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status
  • Format: (000) 000-0000.

  • Emergency Contact Information

  • Format: (000) 000-0000.

  • Preferred Pharmacy

  • Format: (000) 000-0000.

  • Referral Information

  • Were you referred to our practice?

  • Employment Information

  • Format: (000) 000-0000.

  • Insurance Information

  • General Medical Questionnaire

  • Ever you EVER had any of the following?
    Rows
  • Please list all past surgeries and hospitalizations and the approximate date.
  • Please indicate any major conditions/illnesses that your immediate family members have had:
    Rows
  • Do you currently smoke?
  • If no, previously?
  • Do you use other tobacco products?
  • Consume alcohol?
  • If Relevant: Any past pregnancies?
  • Do you have any allergies to medications or other substances (pets, food, etc.)?
  • If yes, please list allergies and reactions (including rash, hives, throat swelling, anaphylaxis):
  •  Please list ALL of your current medications, including over the counter medications, supplements, and herbs: 

  • Release of Personal Medical Information

  • Date Of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do hereby grant permission for Broward Community Medical Center to release my personal medical informationto the individuals below

  • I      grant permission for Broward Community Medical Center to leave messages on my voicemail contained medical information above and beyond appointment times. I understand that I am solely responsible for information left on my voicemail.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • I hereby release the facility from any liability which may arise as a result of the use of information contained in the records released.

  • Date of birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: