Prompt Urgent Care - Patient Registration Form

Patient Registration

Date*

First Name*

Middle Name

Last Name*

Date of Birth*

Age

Sex*

Social Security Number

Cell Phone*

Email Address

Upload Identification Document*

Select Document Type*

ID Card Driver's License

📄 Upload Front Side* 📎 Accepted: JPG, PNG, PDF | Max: 8MB per file

📄 Upload Back Side* 📎 Accepted: JPG, PNG, PDF | Max: 8MB per file

Marital Status

Single Married Separated Divorced Widowed

Home Address*

Apt #

City*

Province/Territory*

Postal Code*

Emergency Contact

Name*

Relationship*

Home Phone

Cell Phone*

Health Insurance Information

Policy Holder

Policy Holder DOB

Policy Holder SSN

Policy Holder Address (if different)

Policy Holder Phone # (if different)

Reason for Visit

Why are you being seen today?

Patient History

Patient's Name (optional)

Date

Medication Allergies

Reaction

Food Allergies

Reaction

Current Medications (including OTC, vitamins, supplements)

You can add as many medications/supplements as needed.

Major Surgeries

Add all major surgeries you have had.

Family History

Relation	Living/Deceased	Age	Major Health Problems
Father
Mother

Father

Living/Deceased

Age

Major Health Problems

Mother

Living/Deceased

Age

Major Health Problems

I confirm the information provided is accurate and complete.*