Pre-Registration Information

    Personal Information

    Include any extension (if required.)

    You must provide at least one of the above three phone numbers.

    Primary Insurance

    Check this box if you are NOT the patient listed above and are filling this form out for another person.

    Secondary Insurance

    Do you have secondary insurance? YesNo

    Workers Comp

    Primary Care Physician

    Note we will fax a copy of the encounter note from today’s visit to your PCP

    Emergency Contact

    Confidential Communication of Personal Health Information

    Please indicate individual (aside from yourself, if not minor), if any, authorized to speak with staff from Your Docs In regarding the patient’s evaluation, diagnosis, treatment and billing.

    Please enter a time (i.e. 4:00 pm) that you would like to be seen. NOTE: The desired time is NOT guaranteed for a walk-in clinic and does not move you to the front of the line.

    Enter your initials to represent your signature.

    Please enter these characters below: captcha