Sugarloaf Urgent Care New Patient Form

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SUGARLOAF URGENT CARE
NEW PATIENT FORM
Today’s date:
/
/
PCP:
PATIENT INFORMATION
Patient’s Last name:
Marital status (circle one)
First:
Single / Married / Divorced /
Middle:
Separated / Widowed
Ye s
No
Is this your legal name?
Email :
If not, what is your legal name?
M
F
Birth date:
/
/
Age:
Sex:
Home/Cell #
Street address:
Social Security #
-
-
(
)
P.O. box:
City:
State:
ZIP Code:
Employer phone
Occupation:
Employer:
no.:
(
)
 Dr.
 Insurance Plan
 Hospital
 Family
How did you hear about us? (please check one box):
 Internet
 Other
Ye llow P a ge s
Pharmacy Name:
Pharmacy phone #:
INSURANCE INFORMATION
(Please give your Picture ID and insurance card to the receptionist)
Person responsible for bill:
Responsible person’s D O B:
/
/
Address (if different):
Home phone no: (
)
Cell phone no: (
)
 Yes
Name of insurance co:
Is this person a patient here?
 No
Employer Name:
Employer phone
Occupation:
no.:
Employer Address:
(
)
Ye s
No
Is this patient covered by insurance?
Primary Insurance Co:
Group no:
Policy no:
Co-pay: $
Subscriber’s Name:
Subscriber D O B:
/
/
 Self
S pous e
Child
Patient’s relationship to subscriber:
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same
Home phone no:
Work phone no:
address):
(
)
(
)
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the
physician. I understand that I am financially responsible for any balance. I also authorize SUGARLOAF URGENT
CARE or insurance company to release any information required to process my claims.
Patient/Guardian Signature:
Date:
/
/

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