New Patient information (latest) .pdf
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
Social Security #: __________________________
Home Phone#: _______________________________
First Name: _______________________________
Cell Phone#: __________________________________
Last Name: ________________________________
Middle Name: ______________________________
City, State: ___________________________________
Emergency Contact: ________________________
Emergency Contact’s Phone #:____________________
How did you hear about us?
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Hispanic or Latino
Not Hispanic or Latino
Black or African American
**ONLY COMPLETE IF YOU DO NOT HAVE YOUR INSURANCE CARD AT TIME OF SERVICE**
ADDRESS (if different than patient information):
RELATIONSHIP TO INSURED:
RESPONSIBLE PARTY (IF MINOR) OR DIFFERENT FROM PATIENT INFORMATION
CITY, ST, ZIP:
AUTHORIZATION & AGREEMENT
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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