Skip to content

Home
Forms
Contact

Home
Forms
Contact

Patient Registration Form

Reason For Visit / Symptoms*
Type Of Visit*
- Work
- Auto
- Personal
Are you a smoker?*
- Yes
- No
Sex*
- Female
- Male
Patient's Name*
First Middle Last
Patient's Date of Birth*
Patient's Social Security Number*
Patient's Phone*
Patient's Email*
Patient's Address*
Street Address City State ZIP Code
Primary Care Physician*
First Last
Primary Care Phone
Emergency Contact Name*
First Last
Emergency Contact Phone*
Relationship of Emergency Contact*
Payment
- Health Insurance
- Auto Insurance
- Employer
- Self-pay
- Other
Other Payment Option*
Primary Insured Name*
First Last
(Name on Insurance Card)
Primary Insured Date of Birth*
Primary Insured Number Social Security*
Primary Insured Sex*
- Female
- Male
Primary Insured Address
Street Address City State ZIP Code
Primary Insured Phone Number
Primary Insured Cell Number
Primary Insured Work Phone
How did you hear about us?*
- Drive-by
- Facebook
- Mail
- Google
- Referred
- Newspaper
- Other
Other

© 2018 Burton Urgent Care