Pre-Register for Your Visit

You can reduce wait times in the emergency room by using our ER Check-In Online online registration service.

To register:

  • Complete the simple form below for regular admission
  • Hit submit for processing

Please remember:

  • Some additional paperwork must be completed in person during admission
  • You must have an updated insurance card and photo ID with you
  • Copies of your completed online admissions form

Phone Registration

If you’d like to receive your pre-registration form in the mail, please contact us at (561) 488-8000.

Diagnostic Imaging Scheduling

To make an appointment for our diagnostic imaging services, please call us directly at (561) 417-7920.



Pre-Registration

Please fill out the form below and we’ll confirm with you when received if you have included a valid email address. At that time we’ll also let you know if we need any additional information.

Fields marked with an asterisk(*) are required.

 

If not from USA, select "Outside U.S."
If not U.S.
mm/dd/yyyy
999-99-9999
999-999-9999
999-999-9999

Employment Information

999-999-9999

Admission Information

Are you a returning patient?*

Are you pregnant?

mm/dd/yyyy
mm/dd/yyyy

Spouse/Guarantor Information (Responsible Party)

If not from USA, select "Outside U.S."
999-999-9999

Emergency Notification

Emergency Contact

999-999-9999

Nearest Relative or Friend (not living with you)

999-999-9999

Primary Insurance Information

Are you insured?*

999-999-9999
999-999-9999
mm/dd/yyyy

Secondary Insurance Information

Do you have secondary insurance?*

999-999-9999
999-999-9999
mm/dd/yyyy
If there is a financial liability (i.e. Co-payment, deductible, etc.) what is your preferred method of payment?


Best way to contact you?

Best time to contact you?


Newsletter Registration