Urgent Care – New Patient Registration Form

  • Form

  • Patient Information

  • Sex at Birth*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Communication Preferences

  • Permission to Text Communications
  • Permission to Email Communications
  • Permission to Leave a Voicemail
  • Marital Status*
  • Race*
  • Ethnicity*

  • IN CASE OF EMERGENCY CONTACT

  • Format: (000) 000-0000.
  • ARE WE ABLE TO RELEASE YOUR HEALTH INFORMATION TO THIS PERSON?

  • PRIMARY CARE PHYSICIAN

  • PREFERRED PHARMACY

  • SELF PAY PATIENTS ONLY

  • PRIMARY INSURANCE INFORMATION

  • Policy Holders Date of Birth
     - -
  • Is patient covered by additional Insurance?

  • SECONDARY INSURANCE INFORMATION

  • Policy Holders Date of Birth
     - -

  • 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.

  • MEDICAL HISTORY

  • CHECK WHICH SUBSTANCES YOU USE AND HOW MUCH YOU USE THEM PER DAY

  • Caffeine*
  • Drugs*
  • Alcohol*
  • Tobacco use
  • Check if your work exposes you to any of the following
  • PAST MEDICAL HISTORY: (Check all that apply for yourself)

  • FAMILY HISTORY

  • Father
  • Mother
  • Brother
  • Sister
  • Other
  • Have any of the above persons have or have had any of the following conditions:
  • Date*
     - -
  • Should be Empty: