New Client Appointment Request


This form is intended for attorneys to assist their clients in setting appointments for a FREE accident injury medical consultation, diagnostics and treatment. Submission of the form is not verification that the client is scheduled - it is merely a request for an appointment.

Please fill out the following form, and a representative from Broward Outpatient Medical Center will call shortly to confirm an appointment time. 

Client Information
Client's Name *
Client's Name
Client's Phone
Client's Phone
Was it a car accident? Motorcycle? Was the patient the driver? When did the accident occur?
Appointment Requsted
Note that the Free Medical Consultation is only available M-F 8am to 7pm, with the last appointment at 6pm. Please schedule request accordingly.
Date of Appointment Request
Date of Appointment Request
Time of Appointment Request
Time of Appointment Request
Law Firm Information
Submitting Attorney/Paralegal/Case Manager
Submitting Attorney/Paralegal/Case Manager
Direct Phone Number (if available)
Direct Phone Number (if available)

NOTE: HIPAA Medical Records Release Form

If you are submitting a client for the first time, it it is important that you file a HIPAA Release Form, or we will not be able to release the client's files to you on request. For a copy of an executable HIPAA Medical Records Release form, please click here: HIPAA Medical Records Release form. Please email the signed HIPAA release to Patientadvocateteam@Browardoutpatient.com