Lansing Urgent Care Patient Registration Form 2026

1. Click ‘Get Form’ to open the Lansing Urgent Care Patient Registration Form in our platform.
2. Begin with Section 1: General Information. Fill in your date, last name, first name, social security number, date of birth, and gender. Provide your home telephone and optional cell phone numbers, along with your street address, city, state, zip code, email (if applicable), marital status, employer details, and primary care physician's name.
3. Proceed to Section 2: Insurance Information. If the insured's information is the same as yours, check the box provided. Otherwise, enter the insured’s date of birth, full name, address details, social security number, gender, phone number, relationship to patient, and employer information.
4. In Section 3: Reason for Visit & Co-Pay Information, specify the reason for your visit and any insurance co-pay amount.
5. If applicable, complete Section 4: Guarantor Information for minors or dependents by providing the guarantor's details including their name, address, phone number, social security number, gender and relationship to the patient.
6. Finally, in Section 5: How did you hear about Lansing Urgent Care?, select from the options provided or write in other sources.

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