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Personal Information Appointment Information Contact information Insurance Information General Information
     
Appointment Date : Invalid Date Online date must be at least 2 days in the future
and cannot be greater than 30 days Appointment Date is Required DOA date error
First Name :   First Name is required
Middle Name :
Last Name :   Last Name is required
Birth Date :   Date of Birth is required Date of Birth is invalid DOB Error
SSN (* Optional): SSN is invalid
Birth Sex :   Birth Sex is required
Legal Sex :   
Address :   Address is required
City :   City is required
State :   State is required
Zip Code :   Zip Code is required
Have you been at Boca Raton Regional Hospital
In the last 30 days? :
  required
Has any demographic information changed? :
  required
Your appointment is for which of the following. (Check all that apply) * Please select procedure

Select procedure
Please specify other Other procedure is required
Breast Care Options
Please specify other Other procedure is required
Body part   Body part is required
Reason for Exam   Reason for Exam is required
Who is the ordering Physician?    Ordering Physician is required
Preferred Date Invalid Date Online date must be at least 2 days in the future
If you need an appointment within the next 24 hours,
please call the scheduling department directly at 561-955-4700 to expedite your request Preferred Date is Required Preferred date error
Preferred Time   Appointment Time is required Preferred time error
Preferred Location
Location is required Preferred location error
You can upload your prescription here  max 4MB Uploading file
Can we leave a text, email or voice message?
Please select one
Can we send you a text message regarding your appointment?
Best Contact Number Required   Phone Number is required Invalid Format (use: XXX-XXX-XXXX)
Alternative Phone Number Required   Invalid Format (use: XXX-XXX-XXXX)
Email Address   Email Address is requiredInvalid Email Address
Do you have access to the Patient's Portal to access your results?
Please select one
Do you want to have access?
Please select one
Emergency Contact Information
Emergency contact name   Emergency contact name is required
Emergency phone number   Emergency Phone Number is required Invalid Format (use: XXX-XXX-XXXX)
Emergency contact relationship to patient   Relationship to patient is required
Confirm Email Address   Confirm Email Address is requiredEmails not matching
Please call for self pay rates 7 days a week 7am to 8pm 561-955-5118
Primary Insurance Information
Insurance Company Name   Insurance Name is required
Insurance Company Phone Number –
Located on back of insurance card 		  Insurance Company Phone Number is required Invalid Format (use: XXX-XXX-XXXX)
Policy Number   Policy Number is required
Policy Name of Insured   Insured Policy Name is required
Policy Holder Name   Policy Holder Name is required
Policy Holder Date of Birth   Primary Policy Holder Date of Birth is required
Relationship to Policy Holder :   Relationship to Policy Holder is required
Secondary Insurance Information
Insurance Company Name
Policy Number
Policy Name of Insured   
Policy Holder Name   
A potentially dangerous Request.Form value was detected from the client
Additional Information
Expected Delivery Date
What is your Primary Care Physician's Full Name? Physician name is required
What is your Primary Care Physician's Name
What is your Primary Care Physician's Phone Number?   Primary Care Physician Phone Number is required Invalid Format (use: XXX-XXX-XXXX)
Do you have a prescription?
Please select one
If you are a new patient or have obtained new insurance, please send front and back copies of your cards to fax 561-955-4154 OR email to PARX@brrh.com

BHSF General Consent Form have been updated, please click here to download a copy. To expedite your registration send us a signed copy of your signed consent form along with your photo ID 561-955-4154 OR email to PARX@brrh.com.

We have a price transparency tool available to check your financial responsibility prior appointment, please note this is not a guarantee of coverage or price until final bill. This is an estimate and not a guarantee of payment. https://www.brrh.com/Patients-Visitors/Transparency-in-Healthcare/Understanding-Prices.aspx
Newborn Insurance Information (If different from yours)
Insurance Company Name
Policy Number
Name of Insured
Policy Holder Date of Birth   
Policy Holder Name   


If you are a new patient or have obtained new insurance, please fax to 561-955-4154 OR email to PARX@brrh.com

BHSF General Consent Form have been updated, please click here to download a copy.

Send us a signed copy with driver's License to fax 561-955-4154 OR email to PARX@brrh.com, this will expedite your appointment.



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