Patient Registration Form – NextCare Urgent Care

PATIENT REGISTRATION FORM
□ New Patient □ Established Patient

PATIENT NAME:
Date of Birth: Sex: □ Male □ Female

Social Security #:
Mailing Address:
Local Address:
Circle One: Apt., Unit, Bldg., Lot, Suite #: Circle One: Apt., Unit, Bldg., Lot, Suite #:
City: State: Zip: City: State: Zip:
Home Phone #: Cellular/Mobile Phone #:
Email Address:

REASON FOR VISIT:
• Is this a Work Related Injury? (circle one):   Yes      No
• If yes, have you notified or do you plan to notify your Employer? (circle one):     Yes    No

How did you hear about us? (select one):
□ Customer Service □ Email □ Facility Signage
□ Family/Friend/Word of Mouth □ Phone Book/Yellow Pages □ Location
□ Internet/Online Search: _______________
□ Print Advertising: ______________
□ Radio: _____________________
□ School/Daycare:________________________________
□ Employer: _____________________________________
□ Community Event: _____________________________
□ Hotel: _________________________________________
□ Physician Referral: _____________________________
□ Pharmacy: _____________________________________
□ Apartment Complex: ____________________________
□ Insurance: _____________________________________

 

INSURANCE DETAILS
Primary Insurance Company: Copay/Coins/Ded Amount:
ID/Policy #: Group #:
Subscriber Name (if applicable): SSN: Date of Birth:
Subscriber’s Address (if applicable): Relationship:
Secondary Insurance Company: ID/Policy #: Group #:
Parent/Legal Guardian of Minor or Incapacitated Adult ONLY
Name: Date of Birth:
Relationship: Contact #:

SIGNATURE

Signature Date