Urgent Care Patient Registration Form

Patient Information

• Full Legal Name: ________________
• Date of Birth: //____
• Social Security Number: --___
• Gender: □ Male □ Female □ Other
• Home Address: ________________
• Phone: (__) -
• Email: ________________
• Preferred Contact Method: □ Phone □ Email □ Text

Emergency Contact

• Name: ________________
• Relationship: ________________
• Phone: (__) -

Insurance Information

• Primary Insurance: ________________
• Policy Number: ________________
• Group Number: ________________
• Policy Holder Name: ________________
• Policy Holder DOB: //____

Current Medical Complaint

• Reason for Visit: ________________
• Duration of Symptoms: ________________
• Pain Level (0-10): __

Medical History

Allergies

□ No Known Allergies □ Medications (List): ________________ □ Other (List): ________________

Current Medications

• Prescription Medications: ________________
• Over-the-Counter Medications: ________________
• Supplements: ________________

Past Medical History

(Check all that apply) □ Diabetes □ High Blood Pressure □ Heart Disease □ Asthma □ Cancer □ Other: ________________

Consent

I certify that the above information is accurate and complete. I authorize the release of medical information necessary for treatment and insurance processing.

Signature: ________________ Date: //____