Get Afc Urgent Care Patient Registration Form 2015

Filling out the AFC Urgent Care Patient Registration Form online can streamline your visit and ensure that all necessary information is collected efficiently. This guide provides detailed, step-by-step instructions to assist you in completing the form accurately.

Follow the steps to successfully complete your online registration.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the 'Patient's Full Name' field and enter your full legal name. This information is essential for your medical records.
3. Next, provide your date of birth. Make sure to use the correct format, typically MM/DD/YYYY.
4. Indicate your sex by selecting the appropriate option: male or female.
5. Enter your Social Security number in the respective field, ensuring accuracy for identification purposes.
6. In the 'Reason for Visit' section, briefly describe the purpose of your visit to assist in proper care.
7. Fill in your home address, including street address, city, state, and zip code. Be thorough to avoid any issues with communication.
8. Provide a phone number where you can be reached, along with an email address for further correspondence.
9. Answer if your visit is a result of a motor vehicle accident by selecting yes or no.
10. Complete the 'Emergency Contact' section by providing the name and phone number of a person who can be contacted in case of an emergency.
11. Identify your primary care physician and their contact information if available.
12. Respond to the survey question on how you heard about AFC Urgent Care.
13. Complete the section regarding preferred language and ethnicity as it is required for demographic data collection.
14. If you are the guarantor, check the box indicating that the information is the same as the patient's. If not, provide the guarantor information, including their name, date of birth, and contact details.
15. Review the section outlining your financial responsibility and sign your name along with the date.
16. Fill in the insurance information, providing details for both primary and secondary insurance if applicable. Include policy ID, subscriber name, and group number.
17. Sign the consent for treatment section, acknowledging your understanding of the treatment being provided.
18. Finish by signing and dating the acknowledgment of the Notice of Privacy Practices.
19. Once you have completed all sections, review the form for any errors. After confirming that all information is accurate, save changes, download, print, or share the form as needed.

Complete your AFC Urgent Care Patient Registration Form online today for a smoother visit.