Patient Registration Form – Broward Community & Family Health Centers

New Patient Registration

Please download and complete the New Patient Registration form then print, sign and bring it with you on your first appointment. Thank you!

We’ve made the registration process for new patients more accessible than ever before! Click on the link below to download our new patient registration forms.

Here are 2 easy steps to submit your form :

Upload your registration form and documents on your myChart profile.
Bring the completed registration form and documents to your appointment.
Bring the completed registration form and documents to your appointment.

If you need assistance filling out the registration form or if you do not have access to a printer, one of our care team members will be more than happy to assist you with this process at any of our centers.

Download Form

Broward Community & Family Health Centers, Inc. is a FTCA deemed facility. This is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). For further information on our FTCA status, please contact BCOM Corporate Office at (954) 266-2999.

Contact Us

5010 Hollywood Blvd.
Hollywood, FL 33021

Tel: (954) 266-2999
Fax: (954) 966-3320

New Patient Registration

Please download and complete the New Patient Registration form then print, sign and bring it with you on your first appointment. Thank you!

Here are 2 easy steps to submit your form :

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