Today’s Date

Reason for Visit:

How did you hear about us?

Name

Age

SSN#

DOB

Sex

Marital Status

Address

City

State

Zip

Home Phone

Cell Cell Phone

Email

Preferred Pharmacy:

Name:

DOB

SSN

Cell Phone

Address

Home Phone

Primary Insurance Name/Self-Pay

Address

City

State

Policy #

Group #

Policy Holder Name Relationship to Patient

DOB

SSN#

Cell Phone

Secondary Insurance Name:

Address

City, State, Zip

Policy #

Group #

Policy Holder Name

Relationship to Patient

DOB

SSN#

Cell

Phone

Authorized signature is on file. By signing, I attest that all information provided is true and correct. I authorize the release of any necessary medical information and payment of medical benefits to the physician for services rendered.
I understand and agree that:
1) I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read) and understood the notice.
2) I am responsible for all charges incurred including the balance remaining after payment of insurance benefits (as per your insurance contract); any third party billing such as labs or medical equipment etc. will become my responsibility
3) Payment is expected on the day services are rendered unless prior arrangements are made.
4) If we are unable to collect for services rendered, your account will be sent to a collection agency and all collection fees will be added to your balance.
** All co-pays are due at time of service.
You expressly consent and agree that, in order to discuss or service your accounts(s) (the “Accounts “) or to collect amounts you may owe, Fast Aid Urgent Care and its officers, agents, affiliates, employees, and any affiliated or associated service providers and any third-party debt collection agency associated therewith (collectively, “We”) may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you. You expressly consent and agree that We may also contact you by sending text messages, emails, using any e-mail address you provide to us, or by pre-recorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and pre-recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile telephone numbers, regardless of whether you incur charges as a result.

Date