Patient Registration Form – NextCare Urgent Care

PATIENT REGISTRATION FORM

□ New Patient □ Established

Patient Patient Name:

Date of Birth: Gender: □ Male □ Female

Social Security #:

Ethnicity/Race:

Local Address:

Apt #:

City:               State:                      Zip:

Cellular/Mobile Phone #:

Home 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):

Secondary Insurance Company:

ID/Policy #:

Group #:

 

Parent/Legal Guardian of Minor or Incapacitated Adult ONLY

Name:

Date of Birth:

Relationship:

Contact #:

 

SIGNATURE __________________________________                     Signature Date________________________________