Patient Registration Form - FastMed Urgent Care 2025

1. Click ‘Get Form’ to open the Patient Registration Form in the editor.
2. Begin by filling in the required fields marked with an asterisk (*). Start with the date, patient name (first, middle, last), and date of birth.
3. Provide your Social Security Number (SSN), sex, and marital status. Next, enter your primary care provider's name and phone number.
4. Complete the contact information section by providing at least one contact number and your mailing address, including city, state, and zip code.
5. Fill in your emergency contact details, including their name and phone number. Don’t forget to provide your email address for important updates.
6. Continue with insurance information by entering the subscriber’s name, relation to you, date of birth, SSN, and employer details.
7. Review financial policies carefully before signing. Ensure all sections are completed accurately before submitting.

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