Pre-Registration for a Medical Procedure

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


Scheduled Location:
Today
Has the patient ever received services at any Nicklaus 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 Information

Today
Gender*:

Parent Information

Today
Is the mother's address the same as the patient's address?:
Today
Is the father's address the same as the patient's address?:

Insurance

Does the patient have Medicaid/Medicare?:
Does the patient have Health Insurance?:
Does the patient have Secondary Health Insurance that may provide additional coverage?:

 

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.