Procedure Pre-Registration

At Bethesda Health, we understand that your time is valuable. For your convenience, you can pre-register for your procedure online!
 
Simply fill out the form below OR click here to print out and complete the Procedure Registration Form. Once completed, please fax the completed form to:
 
Bethesda Central Scheduling
Attn: Pre-registration
Fax: (561) 735-7031

If you have any questions, please call Central Scheduling at (561) 374-5700, prompt 3. 

*Note: To complete our online Maternity Pre-Registration form, please click here. 


 

PROCEDURE INFORMATION

Location of procedure

PATIENT INFORMATION

Marital Status
Race
Ethnicity
What method of communication do you want us to use?

EMPLOYMENT INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

If you have insurance that you would like us to bill for you, please provide the following:
If you do not have insurance and would like a representative to contact you to assist with financial arrangements, please indicate here.

ADDITIONAL INFORMATION

Are the services to be performed the result of an auto accident?
Are the services to be performed the result of a work related injury?
Florida law requires that we inquire about Advance Directives. Do you have a living will or surrogate? If so, please bring copies of your Advance Directives to the Hospital so that it can be placed in your records.
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