This PDF 1.7 document has been generated by Microsoft® Word 2016, and has been sent on pdf-archive.com on 12/03/2018 at 19:43, from IP address 184.176.x.x.
The current document download page has been viewed 132 times.
File size: 165.64 KB (1 page).
Privacy: public file
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
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
New Patient information (latest).pdf (PDF, 165.64 KB)
Use the permanent link to the download page to share your document on Facebook, Twitter, LinkedIn, or directly with a contact by e-Mail, Messenger, Whatsapp, Line..
Use the short link to share your document on Twitter or by text message (SMS)
Copy the following HTML code to share your document on a Website or Blog