Urgent Care – New Patient Registration Form

PRIMARY CARE PHYSICIAN
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PREFERRED PHARMACY
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us
SELF PAY PATIENTS ONLY
By signing below I certify that I do not currently have health care insurance.

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PRIMARY INSURANCE INFORMATION
Insurance Co.
Group #
ID#
Policy Holders Name:

First NameLast Name
Policy Holders Date of Birth

MonthDayYear
Policy Holders SS#
Relationship to Patient
Is patient covered by additional Insurance?

YesNo
SECONDARY INSURANCE INFORMATION
Insurance Co.
Group #
ID#
Policy Holders Name:

First NameLast Name
Policy Holders Date of Birth

MonthDayYear
Policy Holders SS#
Relationship to Patient
ACKNOWLEDGEMENT OF PRIVACY PRACTICES
I have received, read and understand the Notice of Privacy Practices document of the complete description of the uses and disclosures of my health information. I understand that FirstCare Medical has the right to change its Privacy Practices from time to time and that I may contact this organization at any time for a current copy of the Notice of Privacy Practices document.
Signature*

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