top of page

SFLKA NEW LOGO_edited_edited_edited_edit

18004 NW 6th Street Suite 104

Pembroke Pines FL, 33029

Home
About Kidneys
- Nephrology Services
Dialysis Services
Genetics
Clinical Research Studies
More

Use tab to navigate through the menu items.

PATIENT APPOINTMENT

Patient Registration

Patient Registration Form

Personal Information

Full Name

Date of Birth

Age

Sex

Driver’s License / ID

Contact Information

Address

City

State

Zip Code

Phone Number

Alternate Phone

Email Address

Emergency Contact

Name

Relationship

Phone Number

Insurance Information

Insurance Provider

Policy Number

Group Number

Policy Holder Name

Relationship to Patient

Medical Information

Primary Care Physician

Known Allergies

Yes (specify)

Current Medications

Existing Medical Condition

Have you been hospitalized recently

If so which hospital?

Reason for Visit

Consent

I certify that the information provided above is true and correct to the best of my knowledge.

Patient Signature

Guardian Signature (if minor)

Date

Thanks for submitting!

Where To Find Us

18004 NW 6th Street Suite 104

Pembroke Pines FL, 33029

appointment@drmaxbenjaminmd.com

Quick Links

Home
Patient Registration Form
About Kidneys
Genetics
Dialysis Services
Clinical Research Studies

Office Hours

Mon - Thu: 9am - 4:30pm

(954) 885.1024

Fax: (954) 885. 1340

© 2025 South Florida Kidney Associates, PA *** All rights reserved

bottom of page