Patient Pre-Registration Form

We serve patients of all ages

Care Resource’s medical services are available to everyone. We care for men, women, teens, pre-teens and babies. Regardless of your legal status, ability to pay, gender, or age, count on our team to educate, guide, and care for your wellbeing.

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Patient Pre-Registration Form

Care Resource provides services on a sliding fee scale. Fees are based according to family income & size for residents residing within Care Resource’s service area. Learn more

Please complete the short form below and click to submit this request to us. A patient service representative will contact you with an appointment time to complete your registration.

NOTE: A photo ID must be uploaded with this form in order to process your registration. You may take a photo of your ID and other supporting documents, and upload as instructed below. If you have health insurance, please include photos of the front and back of the insurance card. If registering a minor for pediatric care, please attach a copy of the birth certificate and any other legal documents showing guardianship.

Patient Name*
First Last
Patient Date of Birth (MM/DD/YYYY)*
MM slash DD slash YYYY
Parent or Guardian name, if patient is under 18 years old.
When prompted below, please make sure to include a photo ID of the parent or guardian, and/or any other legal documents showing custodian or guardianship of the minor / patient.
First Last
Parent or Guardian Phone, if patient is under 18 years old.
Relationship to Minor, if patient is under 18 years old.
Patient Address:*
Street Address Address Line 2 City State ZIP
Phone*
Email*
Emergency Contact Name:*
First Last
Emergency Contact Phone:*
Emergency Contact Relationship:*
Please select one:*
- New Patient
- Existing Patient (within 2 years)
- Past Patient (over 3 years)
Please indicate what kind of insurance coverage you currently have:*
- Medicare
- Medicaid
- Medicare & Medicaid - Dual Eligible
- Private or Commercial
- Public Insurance - (i.e. CHIP, Ryan White)
- Uninsured
Please select your preferred location:*
- Midtown-Miami
- Miami Beach
- Fort Lauderdale
- Little Havana
Please select the service you are requesting:*
The Dental Department is experiencing a service delay for new insured patients at this time. New patients with Ryan White coverage may continue to request dental care services.
- Covid-19 Testing
- Meningococcal Vaccine
- Dental Services
- Medical Services
- Therapy / Counseling
- Wellness / Preventative
- Housing Assistance
- Nutritionist
- STI Treatment
- PrEP / Pre-Exposure Prophylaxis
- nPEP / Post-Exposure Prophylaxis
- Other service(s) as described below
If you think you’ve been exposed to HIV, time is essential. nPEP / Post-Exposure Prophylaxis must be started within 72 hours after a recent possible exposure to HIV.
Please call or text our nPEP/PrEP hotlines immediately at 754-444-2584 or 786-322-1503 for a response, or visit an urgent care center or an emergency room as soon as possible.
Sex (Assigned at Birth)*
- Male
- Female
Race*
- Asian
- Native Hawaiian
- Other Pacific Islander
- Black/African American
- American Indian/Alaska Native
- White
- More than one race
Ethnicity*
- Hispanic/Latino
- Non-Hispanic
Preferred Language*
- English
- Spanish
- Haitian or Haitian Creole
- Portuguese
Upload Photo ID and Documents*
Attach a copy of a valid government issued photo ID (driver's license, passport, etc.) and the front and back of your health Insurance card (if any). If registering a minor for pediatric care, please attach a copy of the birth certificate and any other legal documents showing guardianship.
Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 300 MB, Max. files: 5.
Consent*
I have read the Patient Rights & Responsibilities, Electronic Consent for Treatment, Financial Policy Acknowledgement, and Grievance Procedure and agree to the terms and conditions.
Comments
This field is for validation purposes and should be left unchanged.

See our full list of health services by clicking on the link below or call 305-576-1234:

> Health Services

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Miami, FL 33137
T: 305.576.1234
F: 305.571.2020

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1680 Michigan Ave. Ste. 912
Miami Beach, FL 33139
T: 305.534.0503
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1901 S.W. 1st St. – 3rd FL
Miami, FL 33135
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871 West Oakland Park Blvd.
Oakland Park, FL 33311
T: 954.567.7141
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Oakland Park, FL 33309

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FTCA HEALTH CENTER This health center 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).

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©2022 Care Resource Community Health Centers, Inc. DBA Care Resource does not discriminate on the basis of race, color, ethnicity, religious creed, age, sex, marital status, national origin, ancestry, sexual orientation, genetic information, physical or mental disabilities (including learning disabilities, intellectual disabilities, past/present history of a mental disorder), prior conviction of a crime (or similar characteristic), workplace hazards to reproductive systems, gender identity or expression, or other legally protected classifications in its programs and activities as required by the 1972, the Americans with Disabilities Act of 1990, Section 504 of the Rehabilitation Act of 1973, Title VII of the Civil Rights Act of 1964, and other applicable statutes and policies. Care Resource is a registered nonprofit. FEI #59-2564198.