Print Friendly and PDF

Pre-Registration

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








Today

Type of Procedure / Treatment / Test

Please select the applicable category below, then select procedure/treatment/test. 


























Patient Information

Today

Parent Information

Today

Today

Insurance





 

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. 


Back
To Top