Boca Raton Regional Hospital Pre-Reg Online

Personal Information Appointment Information Contact information Insurance Information General Information


Appointment Date :
First Name :
Middle Name :
Last Name :
Birth Date :
SSN (* Optional):
Birth Sex :
Legal Sex :
Address :
City :
State :
Zip Code :
Have you been at Boca Raton Regional Hospital In the last 30 days? :	YESNO
Has any demographic information changed? :	YESNO

Can we leave a text, email or voice message?	YESNO
Can we send you a text message regarding your appointment?	YESNO
Best Contact Number
Alternative Phone Number
Email Address
Do you have access to the Patient's Portal to access your results?	YESNO
Do you want to have access?	YESNO

Emergency Contact Information
Emergency contact name
Emergency phone number
Emergency contact relationship to patient
Confirm Email Address

Please check this box if you do not have insurance or your service(s) are not covered by your insurance provider. Prior to your visit, a patient access representative will contact you with payment amount and options. Please call for self pay rates 7 days a week 7am to 8pm 561-955-5118
Primary Insurance Information
Insurance Company Name
Insurance Company Phone Number – Located on back of insurance card
Policy Number
Policy Name of Insured
Please check if you are the primary Insured
Policy Holder Name
Policy Holder Date of Birth
Relationship to Policy Holder :
Secondary Insurance Information
Insurance Company Name
Policy Number
Policy Name of Insured
Policy Holder Name

Additional Information

Do you have a prescription?

YESNO

What is your Primary Care Physician's Full Name?

What is your Primary Care Physician's Phone Number?

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 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

Policy Holder Date of Birth