Metro Urgent Care | Patient Registration Form

URGENT CARE PATIENT INFORMATION

Reason for today's visit *

Last Name *

First Name *

Date of Birth (MM/DD/YYYY) *

Gender *

Male

Female

Non Binary

Patient Address *

Apt# *

City *

State *

Zip Code *

Phone Number *

Patient Email Address *

CONSENT FOR MEDICAL TREATMENT

I give permission to Metro Urgent Care to perform the following services that the medical provider(s) and assistants may deem to be necessary: ( 1 ) medical, surgical, and diagnostic (e.g. : including, but not limited to x-rays, blood draws, and laboratory tests) processes, treatments, and procedures; (2) administration of injections, medications, and immunizations.

Signature *

Date *

CONSENT FOR WELLNESS AND PREVENATIVE HEALTH SCREENING

I give permission to Metro Urgent Care to perform a wellness and / or preventative health screening. I understand that I am solely responsible for following up with my personal physician or other healthcare provider about the results of my screening. In performing the wellness screening, Metro Urgent Care does not assume any responsibility for ongoing treatment or management of care.

Signature *

Date *

TODAY'S PAYMENT

How will you be paying for today's bill? *

Cash

Credit Card

Debit Card

If you have insurance: I understand that I am financially responsible for all charges not covered by my insurance. Initials *

RELEASE OF MEDICAL RECORDS/ ASSIGNMENT OF BENEFITS/ FINANCIAL RESPONSIBILITY

Metro Urgent Care will submit claims to my insurance carrier as well as medical records needed to evaluate the claims for payment. I further assign payments of benefits, otherwise payable to me, to be made to Metro Urgent Care.

I understand that I am financially responsible for all charges not covered by my insurance *

Signature *

Date *

Print Name *

If you do not have insurance: I understand that payment for today's visit will be due today at check-in. If treatment requires more complex evaluations, laboratory tests, vaccinations, medications, x-rays, and or supplies, these will be charged in addition to the appropriate office visit fee.

I do not have insurance and I am responsible for all costs Initials *

NOTICE OF PRIVACY PRACTICES

Your name and signature below indicates that you have been made aware of Metro Urgent Care's Notice of Privacy Practices (NOPP) on the date indicated. You understand that the NOPP is posted and a copy will be provided to you if you request it. If this is your first date of service with Metro Urgent Care, please indicate this to the front desk receptionist and he/she will provide you a copy of the NOPP.

Signature *

Date *

Print Name *