New Patient information (latest) .pdf

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Original filename: New Patient information (latest).pdf
Author: Manager WBUC

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148 Wall Blvd. Gretna, LA 70056 | Phone: (504) 393-2273 | Fax: (504) 393-2744
113 Belle Terre Blvd. LaPlace, LA 70068 | Phone: (985) 359-2273 | Fax: (985) 359-8560
www.TheUrgentCare.com

Patient Information
Social Security #: __________________________

Home Phone#: _______________________________

First Name: _______________________________

Cell Phone#: __________________________________

Last Name: ________________________________

Email: _______________________________________

Middle Name: ______________________________

Birthday: _____________________________________

Sex:

Female

Address:

Male

____________________________

City, State: ___________________________________

____________________________

Zip Code:

Emergency Contact: ________________________

___________________________________

Emergency Contact’s Phone #:____________________

Relationship: ______________________________

How did you hear about us?
Friend/Family

Drive-by

Yelp

Job Posting

Facebook

Flyer

Internet (

Google)

Phonebook

Military Directory

Ins. Directory

Dr. Referral

ADDITIONAL INFORMATION
Race:

American Indian or Alaska Native
Native Hawaiian or Pacific Islander

Ethnicity:

Hispanic or Latino

Preferred Language:

English

Asian
White

Not Hispanic or Latino
Spanish

Black or African American
Patient Declines
Patient Declines

Vietnamese

Other ______________

Patient Declines

INSURANCE INFORMATION
**ONLY COMPLETE IF YOU DO NOT HAVE YOUR INSURANCE CARD AT TIME OF SERVICE**
PRIMARY INSURANCE
PLAN:
MEMBER ID:

NAME OF
POLICY HOLDER:

GROUP#:

ADDRESS (if different than patient information):
SSN#:

DOB:

RELATIONSHIP TO INSURED:

RESPONSIBLE PARTY (IF MINOR) OR DIFFERENT FROM PATIENT INFORMATION
NAME:

DATE OF
BIRTH:

ADDRESS:

CITY, ST, ZIP:

PHONE #:

EMAIL:

AUTHORIZATION & AGREEMENT
Signature:

Date:

I declare that the above information is true. I authorize my insurance benefits to be paid to The Urgent Care. I understand that I am financially
responsible for any charges that may not be covered by my insurance plan. I also authorize my medical information to be released to my
insurance company and any of its affiliates for medical purposes.

Patient Registration Form


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