bcmcfl.com - Patient Registration Form

Release of Personal Medical Information
I (name)
Date Of Birth

MonthDayYear
Date
Last 4 SSN
Do hereby grant permission for Broward Community Medical Center to release my personal medical informationto the individuals below
I DO DO NOT 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.
Patient signature

Clear
Date

MonthDayYear
Date
Witness

Clear
Date

MonthDayYear
Date
I hereby release the facility from any liability which may arise as a result of the use of information contained in the records released.
Print Name
Date of birth

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	Yes	No
Asthma/Breathing Problems
Arthritis
Bleeding/Clotting Disorder
Blood Pressure Disorder
Blood Transfusion
Bowel/Stomach Problems
Cancer
Cholesterol Disorder
Diabetes
Eye Disorder (i.e. Glaucoma, cataract).
If Relevant: Gynecological Issues
Heart Disease/Disorder
Lung Disorder
Liver Disease
Neurological Disorder/Chronic Headaches
Psychiatric Disorder/Illness
Pulmonary Embolism/DVT
Stroke
Seizure or Epilepsy
Thyroid Disorder
Urinary/Kidney Disorder

Patient Registration Form