DFW Urgent Care - Online Registration

Visit DFW For:

Preventive Medicine
Urgent Care
Occupational Medicine
Minor Emergencies
Family Medical Care

If you really want to expedite your visit, you can fill out your registration and personal health information far in advance of coming to DFW Urgent Care. In fact, filling this information out completely will in most cases guarantee you NO WAIT at all!!!

Patient Information
Patient’s Last Name:
First Name:		M.I.
Address:		Apt.
City:		State:
Zip:
Home Phone:
Work Phone:		Ext:
Cell Phone:
Date of Birth:		Age:
Email Address:		Sex:	M F
Drivers License #:		Marital Status:
Social Sec. #:		Sin. Mar. Div.

Employer:
Employer Address:		City:
State:		Zip:

Spouse’s Name:
Social Sec. #:
Work Phone:


Guarantor Information
Guarantor Name:
Date of Birth:
Relationship:
Address:		Apt.#
City:
State:		Zip:
Home Phone:
Work Phone:		ext.:
Cell Phone:

Employer:
Employer Address:		City:
State:		Zip:

Social Security #:
Age:		Sex:	M F


Insurance Information
Information must be completed even if we have a copy of your insurance card.
Primary Insurance Carrier
Phone:
I.D. #
Subscriber’s Name:		Sex:	M F
Date of Birth:
Relationship:

Secondary Insurance Carrier
Phone:
I.D. #
Subscriber’s Name:		Sex:	M F
Date of Birth
Relationship:


Additional Information
How did you hear about our facility:	Mailer Physician Phone Book Google MSN Yahoo Insurance Web site Other:
Emergency Contact:
Address:
Phone:

ALL CHARGES ARE DUE AT TIME OF SERVICE. NOTE: You may receive a separate bill from the lab that analyzes the following services rendered: Blood tests, Pap smears, Cultures (throat, cervical, urine, etc.) and any biopsies performed. In order to submit a claim for payment to us for services covered under your insurance policy, we must have your authorization to release medical information to your insurance carrier. Medicare I request that payment of authorized Medicare benefits be made either to me or on my behalf to DFW Urgent Care P.C. for any services furnished me by their physician. I authorized any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I hereby authorized Medicare to furnish the above named doctor any information regarding my Medicare claims under title XVIII of the Social Security Act. Commercial Insurance: I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to the doctor or group indicated on the claim. I understand I am financially responsible for any balance not cover by my insurance carrier. A copy of this signature is as valid as the original. I understand that an additional fee may be added if my account becomes delinquent.

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