Get New Patient Registration Form - Paramount Urgent Care

Completing the New Patient Registration Form for Paramount Urgent Care online is a straightforward process designed to gather essential information for your visit. This guide will walk you through each section of the form, ensuring you provide all necessary details efficiently and accurately.

Follow the steps to successfully complete your registration form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in the date and select any applicable self-pay or insurance options. Indicate how you heard about the facility.
3. Enter your personal information, including first name, middle initial, last name, date of birth, age, and sex.
4. Input your address, city, state, zip code, and phone numbers (home, cell, and work). Provide your personal and confidential email addresses.
5. Enter your social security number and marital status, selecting from the given options.
6. Select your employment status and, if employed, provide your employer’s name.
7. List your emergency contact details, including their name, relationship to you, and their contact numbers.
8. If under 18, complete the spouse or guarantor data section, providing their occupation and contact details.
9. Complete the insurance information section by entering both primary and secondary insurance details, as well as the insured name and date of birth.
10. Select your race and preferred spoken language from the given lists, and specify your ethnicity if desired.
11. Review and sign the Patient Responsibility Disclosure Statement, acknowledging your understanding of financial agreements and responsibilities.
12. Provide the reason for your visit, including any related symptoms.
13. Complete the medical history section, indicating personal and family medical history, as well as any medications and allergies.
14. Finally, review all entered information for accuracy, then save your changes, and choose whether to download, print, or share the completed form.

Begin your registration process by completing the New Patient Registration Form online.