Get Mi Lansing Urgent Care Patient Registration Form 2017-2025

Filling out the MI Lansing Urgent Care Patient Registration Form online is an essential step in ensuring a smooth visit. This guide will walk you through the entire process, helping you provide the necessary information accurately and efficiently.

Follow the steps to complete your patient registration form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your general information. Fill in your first name, last name, gender, date of birth, and social security number. Ensure that you provide accurate contact information, including your home, cell, and work phone numbers, as well as your email address.
3. In the emergency contact section, provide the name and phone number of a person who can be reached in case of an emergency.
4. Next, indicate your primary care physician’s information. Fill in their phone and fax numbers, and select whether you would like to receive billing statements electronically by providing your confidential email address if applicable.
5. Move on to the insurance subscriber information. If the subscriber (primary cardholder) is the same as the patient, check that box, and skip to the next section. Otherwise, fill in their name, address, date of birth, social security number, and insurance co-pay amount.
6. For the reason for your visit, briefly describe the purpose and indicate whether it is related to a work injury, an auto accident, or another type of accident. Fill in the relevant details for any accidents mentioned.
7. If the patient is a minor or dependent, fill out the responsible party information. This section includes the name, relationship to the patient, social security number, date of birth, address, and contact details of the responsible adult.
8. Indicate how you heard about Lansing Urgent Care by selecting one of the options listed.
9. Complete the visit follow-up communication section by signing to agree to be contacted for feedback after your visit.
10. If applicable, fill out the employer information section in case of work-related injuries, including employer name, contact information, and details about the injury.
11. If you have secondary insurance, fill out that information as well.
12. Finally, review all entered information for accuracy and completeness. Save your changes, and choose to download, print, or share the completed form as needed.

Complete your MI Lansing Urgent Care Patient Registration Form online today to ensure your visit is efficient and smooth.