Urgent Care Pre-Registration - Crozer-Keystone Health System - PA

Urgent Care Pre-Registration

To help us better serve you, please fill out the following pre-registration form and click the 'Submit' button when you are done.

* Denotes required fields

Patient Information

Type of Phone
 

Location

* Which urgent care location will you be visiting?

Reason for Your Visit

* Was this problem caused by an injury?
* Was the injury job-related?
If on the job, was it reported?
* Have you ever had surgery?
* Have you ever been treated for any of the following? Please check all that apply.
* Have any of your FAMILY MEMBERS had any of the following (check all that apply)
* Do you use tobacco?
* Are you a former smoker?
* Do you drink alcohol?

Emergency Contact

Primary Care Provider

Do you have a primary care provider?

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

Pharmacy

Insurance Information

Do you have insurance?

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

Do you have secondary and/or supplemental insurance?

If yes, please provide information below:

Are you the policy holder or subscriber of the insurance?

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

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