Patient Registration Form - FastMed Urgent Care 2025

1. Click ‘Get Form’ to open the Patient Registration Form in the editor.
2. Begin by entering the date at the top of the form. This is essential for record-keeping.
3. Fill in your full name, including first, middle, and last names. Ensure accuracy as this will be used for identification.
4. Provide your date of birth and Social Security Number (SSN). These fields are marked with an asterisk (*) and must be completed.
5. Indicate your sex and marital status by selecting the appropriate options provided.
6. Enter your primary care provider's name and contact number, along with your mailing address, city, state, and zip code. At least one contact number is required.
7. Complete the emergency contact section with their name and phone number. This information is crucial for urgent situations.
8. Fill out insurance information if applicable, including subscriber details and relation to you.
9. Review financial policies carefully before signing at the bottom of the form to acknowledge understanding.

Start filling out your Patient Registration Form today using our platform for a seamless experience!