Follow the steps to complete your intake form smoothly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin with the type of visit section. Select whether you are here for insurance, an on-the-job injury, self-pay, or other types of visits. Make sure to provide relevant details where applicable.
3. Fill in your personal information. Include your last name, first name, middle name, date of birth, social security number, sex, and marital status.
4. Enter your contact details, including your street address, home phone, cell phone, and work phone. Specify your preferred communication method.
5. Indicate whether you would like to receive messages regarding your care at your preferred phone number by selecting yes or no.
6. In the reason for today’s visit section, explain your symptoms or the purpose of your visit.
7. If applicable, indicate whether this visit is due to an on-the-job injury and provide details about your employer, supervisor, address, and a description of your symptoms or injury.
8. Fill in how you heard about the facility, choosing from options such as signage, referrals, or advertising, and adding details where necessary.
9. If applicable, provide details of the parent or guarantor's information, including their name, date of birth, social security number, and contact details.
10. Enter your insurance information carefully. Include the insurance carrier, subscriber ID, group number, policyholder name, card number, card date, and claim address.
11. Provide the name and contact information for your primary care physician and indicate whether you would like a copy of your chart faxed or mailed.
12. List any medications you are currently taking, known allergies, and additional conditions you would like to discuss with the physician.
13. Review the authorization and release section. Read attentively and sign to authorize treatment, insurance benefits, payment guarantees, and release of records.
14. Once you've completed all sections, ensure all information is accurate. You can then save changes, download, print, or share your completed form as needed.

Complete your documents online today for a streamlined urgent care experience.