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.

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