24-Hour Hotline: (305) 774-3616

Registration Forms

PROCEDURES FOR REGISTRATION & REFERRAL OF PATIENTS 

Appointments for primary care services at BANYAN COMMUNITY HEALTH CENTER may be made by submission of our electronic PATIENT REGISTRATION forms which must be signed either physically or electronically by the patient. We will issue an appointment within 24 hours of receiving the completed PATIENT REGISTRATION package for an appointment within 7 days. 

Please note that we also have a Walk-in Policy for patients who need primary health access sooner. For questions or support, please call us at (305) 774-3400. 

REGISTRATION INSTRUCTIONS 

I. BEFORE SEPTEMBER 15, 2015 Please download the PATIENT REGISTRATION package on this page. The forms are editable and can either be printed and physically completed and signed by patients OR prepared electronically with the patient’s electronic signature (simple instructions for creating an electronic signature are contained within the package). When the registration package is complete, please email to patientregistration@banyanhealth.org. Health center intake staff will respond within 24 hours to the sender with an appointment within 7 days. Please include your name and organization or name and Banyan department in the subject line of the email. 

II. AFTER SEPTEMBER 15, 2015 Our PATIENT PORTAL will be installed by September 15th and available on these pages. At that time, the PATIENT REGISTRATION forms will be able to be prepared, electronically signed by patients, and submitted online. Once launched and available on these pages, our Patient Portal will provide health center patients with more comprehensive access to their medical information. Once patients come for their appointment, they will be issued a PATIENT PORTAL PIN number and instructed in use of the PORTAL for making clerical, medical, and financial inquiries, effecting changes to demographic information, and viewing their medical records. 
 

COMPLETE REGISTRATION PACKET

Complete Registration Documentation (   English Form  |  Spanish Form  )

INDIVIDUAL FORMS 

Registration Information   (  English Form  |  Spanish Form  )
General Consent for Treatment   (  English Form  |  Spanish Form   )
Notice of Privacy Practices   (  English Form   |  Spanish Form   )
Patient History Form   (  English Form  |  Spanish Form  )
Designation of Healthcare Surrogate   (  English Form   |  Spanish Form   )
Advance Directives   (  English Form  |  Spanish Form  )