Patient Forms · Registration

Patient Registration

Your contact details, insurance and billing authorization — about 8 minutes. New patients can complete the full New Patient Packet (opens in a new tab) instead, which includes this form.

Send it online when you finish, or print it and bring it to your visit. What you send goes securely to our office’s patient system. Nothing is sent until you press Send, and nothing you type is saved on this device.

Start ↓ Print a blank copy (opens in a new tab)

This is a blank copy for printing.

Urological Consultants of Florida
12411 Biscayne Boulevard, North Miami, FL 33181 · (305) 672-4222 · www.miamiurologyconsultants.com

Patient RegistrationREG-1 · v2026.11.1

Patient Registration

About 8 minutes · REG-1 · v2026.11.1

All fields are required unless marked (optional).

About you

Legal first name

Middle name or initial (optional)

Last name

Preferred name (optional)

What you would like us to call you, if different.

Date of birth

MM/DD/YYYY

Sex listed on your insurance card

We use this only to match your insurance records.

Male (M)Female (F)X

Gender identity (optional)

ManWomanTransgender manTransgender womanNon-binaryAnother identityPrefer not to say

Your gender identity (optional)

Pronouns (optional)

He/himShe/herThey/themOther

Your pronouns (optional)

Social Security number (optional)

Optional. Some insurance plans use it to confirm your identity and coverage; leave it blank if you prefer.

Marital status (optional)

SingleMarriedPartneredDivorcedWidowedSeparatedPrefer not to say

Preferred language (optional)

For example English, Spanish, Haitian Creole, Portuguese.

I would like an interpreter at my visit

Race and ethnicity (optional)

Optional — select all that apply. We ask every patient for health-equity and quality reporting; your answer never affects your care.

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhitePrefer not to say

How to reach you

Street address

Apt or unit (optional)

City

State

ZIP code

Mobile phone

No mobile? Enter your main phone number.

Home or other phone (optional)

Email address (if you have one)

Preferred way to reach you

Call my mobileText my mobileEmailCall my home or other phone

May we leave a voicemail with appointment details? (optional)

YesNo

Yes — text me appointment reminders and messages about my care at the mobile number above.

Optional, and not needed to be our patient. These texts are for appointments and your care only: we do not send marketing or promotional text messages. Message and data rates may apply. Tell us at any time if you want them to stop.

How did you hear about us? (optional)

My doctor referred meFriend or familyInternet searchMy insurance directoryOther

If the patient is under 18

A parent or legal guardian completes this part.

Parent or guardian name

Relationship to the patient

Parent or guardian phone

Parent or guardian email (optional)

Emergency contact

Name

Relationship to you

Phone

Your doctors

I don't have a primary care physician

Primary care physician (optional)

Their practice or phone (optional)

Referring physician, if any (optional)

Their practice or phone (optional)

Have you seen a urologist before? (optional)

YesNo

Urologist's name (optional)

Insurance

Please bring your insurance card(s) — we'll scan them at the front desk.

I don't have insurance, or I will pay for my own care

Primary insurance

Insurance company

Type of plan (optional)

HMOPPOMedicareMedicare AdvantageMedicaidOther or not sure

Member ID

Group number (optional)

Whose name is the policy in (the subscriber)?

MineMy spouse or partnerMy parentSomeone else

Subscriber's full name

Subscriber's date of birth

MM/DD/YYYY

Subscriber's employer (optional)

I have a second insurance plan

Secondary insurance

Insurance company

Type of plan (optional)

HMOPPOMedicareMedicare AdvantageMedicaidOther or not sure

Member ID

Group number (optional)

Whose name is the policy in (the subscriber)?

MineMy spouse or partnerMy parentSomeone else

Subscriber's full name

Subscriber's date of birth

MM/DD/YYYY

Your pharmacy

Pharmacy name (optional)

Location (optional)

Street or cross streets, or “mail order”.

Pharmacy phone (optional)

Medical authorization and signature

MEDICAL AUTHORIZATION AND LIFETIME PATIENT SIGNATURE

I request that payment of authorized insurance benefits either to me or on my behalf be made payable to UROLOGICAL CONSULTANTS OF FLORIDA, P.A. for any services furnished me by that doctor. I authorize any holder of medical information about me to release to the health care financing administration and its agents any information needed to determine these benefits or the benefits payable for related services. I also understand that if my insurance company does not provide payment to UROLOGICAL CONSULTANTS OF FLORIDA, P.A., I will be billed and agree to pay for said services. I agree to pay for services rendered, including attorney’s fee, collection charges and court cost necessary to effect payment of this account. I also understand that interest charges of 1 ½ % per month may be charged should my account become delinquent.

A photocopy of this authorization shall be considered as effective and valid as the original.

(Your signature is required which will allow us to bill your insurance company.)

Who is signing?

The patientA parent, guardian or personal representative

Representative's full name

Relationship or authority to act for the patient

Lifetime Patient Signature — type your full legal name

Signature of patient or personal representative

Date

I intend this typed name to be my signature, and I agree to sign this authorization electronically.

Review and send

When you have finished, send your answers to our office. Nothing is sent until you press Send to the practice. You can also print your form and bring it instead.

Email me a receipt with my reference number — no medical details

Website

Ready to send

You can still scroll up and change any answer before you send.

Received — reference

Your forms are with our office. Our staff will review them and file them into your chart before your visit. Please keep your reference number.

This erases everything you have typed on this page.

Sent securely to our office’s patient system. This page does not save what you type on this device.

What to bring to your visit

Photo ID
Your insurance card(s)
Your medication list or bottles
Any referral or recent records, if you have them

Questions? Call (305) 672-4222, Monday–Friday, 9:00 am – 5:00 pm.