Get Urgent Care Center Patient Info. Form - Broward Health - Browardhealth

Filling out the Urgent Care Center Patient Info. Form is an essential step in receiving timely medical care at Broward Health. This guide will walk you through each section of the form, ensuring that you provide all necessary information accurately and efficiently.

Follow the steps to complete your patient information form online.

1. Press the ‘Get Form’ button to access the Urgent Care Center Patient Info. form and open it in your editor.
2. Begin by filling out your patient information. Enter your full name, social security number, and indicate if you have been treated at the Urgent Care Center before by selecting 'YES' or 'NO'.
3. Next, provide details about any advance directive you may have. If applicable, indicate 'YES' or 'NO' and optionally note if you can provide a copy.
4. Complete your local address, ensuring you include the city, state, and zip code. If you have an out-of-state address, fill that section out as well.
5. Input your phone number for easy contact and provide your birth date along with your gender by selecting the appropriate option.
6. Add your marital status and race into the designated fields.
7. If the patient is under 18 years of age, complete the guarantor information section. Fill in the guarantor's name, relationship to the patient, address, phone number, social security number, and birth date.
8. Fill out the employment information by providing your employer's name, phone number, address, and your occupation.
9. Describe the reason for your visit by detailing your symptoms or concerns. Also indicate if you have been previously treated for the same reason and if this visit relates to an accident or injury.
10. If there was an accident or injury, provide the date, time, location, and description of how it occurred. Indicate if your employer has been informed about a work-related injury.
11. In the insurance information section, fill out your insurance plan name, the name of the insured, relationship to the patient, and the insured policy ID and group numbers. Also, include the insured's social security number, birth date, and the effective date of insurance.
12. At the bottom of the form, verify that the information you provided is accurate by signing as the patient or guarantor and dating the form.
13. Once the form is fully completed, you can save changes, download, print, or share the form as needed.

We encourage you to complete your patient information form online to ensure a smooth visit to the Urgent Care Center.