Thank you for choosing FastMed Urgent Care. In order to serve you properly the following information is needed. All information will remain confidential. Please fill out all sections that apply to you.

Patient Information

Name

Email Address

Please provide your email address so that we can let you know about any insurance carrier changes, health alerts, changes in hours for our clinics, new locations, staff, FastMed services and other important issues. Information will not be provided to a third party.

Personal Information

Contact Numbers

Mailing Address

Primary Care Physician

Emergency Contact

2012 US Federal Government Requirements

Responsible Party-Complete for Minor Patients OR when Patient is NOT Financially Responsible for Account

Personal Information

Mailing Address

Insurance Information

Personal Information

Employer

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and take it with you to your local FastMed.