Follow the steps to complete your patient registration form successfully

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your general information in Section 1. Fill in your last name, first name, middle initial, date of birth, and social security number. Ensure you provide your complete street address, city, state, zip code, and multiple phone numbers including home, cell, and work. Additionally, specify your preferred method of contact.
3. In Section 2, enter the insurance information. Provide details for the primary cardholder including their last name, first name, middle initial, social security number, address, phone number, date of birth, and employer. If the cardholder's information is the same as yours, check the designated box to proceed to Section 3.
4. For Section 3, state the reason for your visit and any insurance co-pay amount. Indicate whether this visit is work-related, auto accident related, or related to another accident. Complete any additional fields that arise based on your answers.
5. Section 4 is for guarantor information if the patient is a minor or dependent. Add the guarantor's details such as their name, social security number, address, phone number, and relationship to the patient.
6. Move to Section 5 and select how you learned about Lansing Urgent Care from the listed options.
7. In Section 6, provide employer information, only needed if your visit relates to work-related illness or injuries. Fill in the employer name, contact name, contact department, address, phone number, and any relevant details about the injury.
8. Complete Section 7 if you have secondary insurance. Input the same details as required in Section 2 for the secondary cardholder.
9. After filling in all sections of the form, review your entries for accuracy. You can then save your changes, download, print, or share the form as necessary.

Begin filling out your MI Lansing Urgent Care Patient Registration Form online today!