Urgent Care Pre-Registration

* Denotes required fields

Patient Information

* First Name

M.I.

* Last Name

* Date of Birth mm/dd/yyyy

Social Security Number Example: 000-00-0000

E-mail

* Gender

* Address

City

State Example: NY

* ZIP Code Example: 12345

* Phone Number Example: 123-123-1234

Type of Phone

Home
Cell
Business

Authorized to Leave Voice Mail

Location

* Which urgent care location will you be visiting?

Broomall
West Chester

Reason for Your Visit

* Describe what brings you to the office:

* Was this problem caused by an injury?

Yes
No

If yes, what date did it occur? (mm/dd/yyyy)

* Was the injury job-related?

Yes
No

If on the job, was it reported?

Yes
No

* Have you ever had surgery?

Yes
No

If yes, please list surgeries performed and approximate dates:

* Please list any recent hospitalizations and approximate dates:

* Please list current medications (including over-the-counter):

* Please list any drug allergies or intolerances, and provide reactions to same:

* Have you ever been treated for any of the following? Please check all that apply.

Alzheimer’s
Anemia
Anxiety or Depressive
Asthma
Bleeding Disorder
Bone Spurs
Cancer
Chest Pain-angina
Colitis
Diabetes
Ear Problems
Eczema
Elevated cholesterol
Emphysema
Epilepsy
Eye Disorders
Fibromyalgia
Fractures of foot, ankle or leg
Frequent Indigestion
Gonorrhea
Gout
Headache
Heart Attack
Heart Conditions
Hepatitis
Hiatal Hernia
High Blood Pressure
HIV
Hives
Joint Swelling
Keloid/Thick Scar
Kidney Disease
Leg Cramps
Liver Disease
Low Back Pain
Lung Cancer
Nerve Disorder
Osteoarthritis
Phlebitis (blood clots)
Poor Circulation
Psoriasis
Rheumatic Fever
Rheumatoid Arthritis
Scarlet Fever
Sciatica
Scleroderma
Sickle Cell Anemia
Sinus Problems
Skin Cancer Disorders
Skin Condition
Stomach Ulcers
Stroke
Syphilis
Tarsal or Carpal Tunnel Syndrome
Throat Conditions
Thyroid Disease
Tuberculosis
Venereal Disease
None of the above

* Have any of your FAMILY MEMBERS had any of the following (check all that apply)

Birth Defects
Bleeding Disorders
Cancer
Diabetes
Heart Disease
Stroke
None of the above

Please indicate relationship to any of the above checkboxes:

* Do you use tobacco?

Yes
No

If yes, how many cigarettes, cigars, etc do you smoke per day?

* Are you a former smoker?

Yes
No

If yes, when did you quit? (mm/dd/yyyy)

* Do you drink alcohol?

Yes
No

If yes, how many drinks/day?

Emergency Contact

* First Name

* Last Name

* Phone Example: 123-123-1234 x123

* Relationship

Primary Care Provider

Do you have a primary care provider?

Yes
No

If yes, please provide their name/contact information below:

First Name

Last Name

Office Phone Example: 123-123-1234 x123

Address/Location

Pharmacy

Pharmacy Name

Pharmacy Phone Example: 123-123-1234 x123

Address/Location

Insurance Information

Do you have insurance?

Yes
No

If yes, please fill in all applicable fields below so that we may bill your insurance provider on your behalf:

Name of Insurance

Policy/Member ID

Group Number (If Applicable)

Do you have secondary and/or supplemental insurance?

Yes
No

If yes, please provide information below:

Name of Insurance

Policy Number

Are you the policy holder or subscriber of the insurance?

Yes
No

If no, please provide the following information so the claim will be submitted correctly:

Subscriber First Name

Subscriber Last Name

Subscriber Date of Birth (mm/dd/yyyy)

Relationship to Patient

Subscriber Social Security Number (if known) Example: 000-00-0000

Notice of Privacy Practices

* Please review the Notice of Privacy Practices in the link above.

I acknowledge that I have reviewed the Notice of Privacy Practices for Crozer-Keystone's urgent care centers.

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Patient Information

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Reason for Your Visit

Emergency Contact

Primary Care Provider

Pharmacy

Insurance Information

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Urgent Care

Urgent Care Pre-Registration

Patient Information

Location

Reason for Your Visit

Emergency Contact

Primary Care Provider

Pharmacy

Insurance Information

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