Patient Registration
We are committed to providing the best, most comprehensive care possible. Please assist us by providing the following information. All information is confidential and is released only with your consent. If you have questions please contact us at 1-866-MXM-HLTH or feedback@maxemhealthurgentcare.com.
Patient's Personal Information
Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Today
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Month
-
Day
Year
Date Picker Icon
Social Security Number
*
Gender ID
*
Please Select
Male
Female
Female-To-Male (FTM/Transgender Male/Trans Man)
Male-To-Female (MTF/Transgender Female/Trans Woman)
Genderqueer
Choose not to disclose
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home/Cell Phone
*
Please enter a valid phone number.
Email
example@example.com
Preferred Language
*
Please Select
English
Spanish
Other
Race (Select all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Other
Urgent Care Location:
*
Please Select
D'Iberville - 10319 D'Iberville Blvd, D'Iberville, MS
Flowood - 2605 Courthouse Circle, Flowood, MS
Hammond - 2741 W Thomas St Suite A, Hammond, LA
Hattiesburg - 6096 US Highway 49, Hattiesburg, MS
Lake Oswego - 17437 SW Boones Ferry Rd #100, Lake Oswego, OR
Magee - 1529 Suite A Hwy 49 S, Magee, MS
McComb - 101 A Edgewood Drive, McComb, MS
Milwaukie - 10582 SE 32nd Ave, Milwaukie, OR
Mobile - 535 Schillinger Rd S Suite A, Mobile, AL
Oak Grove - 4910 Old Highway 11, Hattiesburg, MS
Ocean Springs - 1514 Bienville Blvd, Ocean Springs, MS
Orange Grove - 10556 Highway 49, Gulfport, MS
Pascagoula - 2210 Denny Ave, Pascagoula, MS
Petal - 100 Eastbrook Drive Suite 30, Petal, MS
Picayune - 422 Memorial Blvd, Picayune, MS
Slidell - 170 North Shore Blvd, Slidell, LA
St. Martin - 6615 Washington Ave, Ocean Springs, MS
Pharmacy
*
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Parent/Guardian Information (ONLY if patient is under 18)
Parent/Guardian First/Last Name
First Name
Last Name
Parent/Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Home/Cell Phone
Please enter a valid phone number.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relation to Patient
*
Emergency Phone
*
Please enter a valid phone number.
Please upload a photo of your insurance card (front & back)
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If you cannot upload a photo of your insurance card, please complete the fields below:
Insurance Name
Policy Number
Group Number
Policy Holder's Name
First Name
Last Name
Policy Holder's Date of Birth
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Month
-
Day
Year
Date
Interpretation Required?
Please Select
Yes
No
How did you hear about us?
Please Select
Radio
Newspaper
Yellow Pages
Family/Friend
Social Media
TV
Other
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Except for services covered by my insurance coverage plan, I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office are due at the time of service. I also understand that the charges not covered by insurance remain my responsibility and assign insurance benefits to this office. In the event my account is turned over to a collection agency, I agree to pay all costs of collection fees and/or attorney's fees and all court costs if any.
*
I authorize Maxem Health Urgent Care to contact me via voicemail, email, and text at the telephone numbers and email address provided above. I understand this could result in a charge from my phone or device carrier to me for talk time, SMS messaging/texts or data usage for emails or voice mails. I understand that voicemail, email, and text messaging are not secure formats of communication. There is some risk that individually identifiable health information or other confidential information contained in such voicemail, email, and text may be misdirected, disclosed to, or intercepted by unauthorized third parties. I may revoke or withhold my consent to use any one or more of these means of communication at any time for my health information but will maintain at least one method for Maxem Health to contact me for billing and insurance issues.
*
I, the undersigned, consent to the care and treatment by the attending provider, his/her associates or assistants and acknowledge that no guarantees have been made as to the effect of such treatment.
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I certify that the information included in these forms are correct to the best of my knowledge. I will not hold the doctor/provider or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
*
I have reviewed the Notice of Privacy Practices as provided at registration and understand that I may request a copy of the policy at any time.
*
Date
*
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Month
-
Day
Year
Date
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