Check In Worksheet .pdf
Original filename: Check In Worksheet.pdf
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CHECK IN WORKSHEET
Name: _________________________________________, ______________________________________________
Date of Birth: ______/______/________
Phone Number: _________________________________
Address: _______________________________________________________ Apt/Suite: ______________________
City: ________________________________ State: _____________________ Zip Code: ______________________
Are you here for a school or work physical?
Are you here due to injuries from a car accident?
Are you here due to injuries related to work?
Would you like a flu vaccine today?
Do you need a doctor’s note for school or work?
Preferred Pharmacy: _________________________ Cross Streets/Address: _______________________
Primary Insurance: ___________________________ Secondary Insurance: _______________________
How would you like us to educate you on your diagnosis? (Circle all that apply)
HIPAA Patient Consent
By signing below, I have read and fully understand the Patient Consent for Use and Disclosure of Protected Health
Information, revised July 2016. I consent and agree to all of its terms and conditions. I understand copies of The Urgent
Care’s full Notice of Privacy Practices are available for me at my request.
By signing below, I have read and fully understand The Urgent Care’s Patient Responsibility, revised July 2016. I accept and
agree to all of its terms and conditions. Specifically, I understand that I am responsible for any medical treatment and
medical equipment not covered by my insurance plan or applied towards my deductible. Please refer to Patient
Responsibility notice on clipboard.
Consent for Treatment
By signing below, I understand that I have a choice to be seen at The Urgent Care versus the hospital Emergency Department,
my primary care, or a specialist. I authorize The Urgent Care to provide medical treatment and services to me. I understand I
am authorizing The Urgent Care to treat me while I seek care from The Urgent Care or until I withdraw my authorization in
Signature: ___________________________________________________ Date: ________/________/__________
If you do not want to receive a call back after your visit, please check here.
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