Patient Information

Patient Name:

Patient Address:

City:

State:

Zip:

Home Telephone:

Cell Number:

Work Phone Number:

SSN:

DOB:

Age:

Gender: Gender: M F

Emergency Contact Information

Emergency Contact Name:

Emergency Contact Phone Number:

Relationship to Patient:

Please provide YOUR information if patient is UNDER 18:

Guardian Name:

Guardian Address:

City:

State:

Zip:

Phone Number:

Guardian SSN:

Guardian DOB:

Guardian's Relationship to Patient:

Email:

How you heard about us:

PHARMACY:

Insurance Information

Primary Insurance:

Policy Holder Information (write "same:" if same and add employer:

Policy Holder Name:

Policy Holder SSN:

Policy Holder DOB:

Employer:

Relationship to patient: Relationship to patient: SELF SPOUSE PARENT CHILD

Secondary Insurance:

Policy Holder Information (write “same:” if same and add employer):

Secondary Policy Holder Name:

Secondary Policy Holder's SSN:

Secondary Policy Holder's DOB:

Secondary Policy Holder's Employer:

Secondary Policy Holder's Relationship to Patient: Secondary Policy Holder's Relationship to Patient: SELF SPOUSE PARENT CHILD

I hereby authorize Walk-In Medical Care to release my records to:

(Name of records released to)

I hereby authorize Walk-in Medical Care to check eligibility on my behalf for covered services rendered by them. I authorize the release of any necessary information, including medical information, to my insurance carrier.

I understand and agree to be responsible for any portion of this claim that for any reason is not covered by my insurance and understand that it is my responsibility to make sure that my medical visits are paid in full.

(responsible party’s initials)

You agree to reimburse us the fees of any collection agency if debt is not paid more than 120 days after the first statement is sent, which is a percentage of 35% of the debt owed, and all costs and expenses we incur in such collection efforts, as well as any service charges assessed to accounts with returned checks. I further consent that I authorize to be treated by the physicians and medical staff within the Walk-In Medical Care facility. I further certify that the information I provided above is true and correct.

Parent/Guardian Electronic Signature:

Date:

Patient Electronic Signature: