Registration Form - Lansing Urgent Care 2025

1. Click ‘Get Form’ to open the Registration Form - Lansing Urgent Care in the editor.
2. Begin by filling out the General Information section. Enter your first and last name, gender, date of birth, and social security number. Ensure that your contact details, including home, cell, and work phone numbers, are accurate.
3. Provide your address details including street address, apartment number (if applicable), city, state, and zip code. Select your preferred method of contact by circling home, cell, or work.
4. In the Insurance Subscriber Information section, fill in the primary cardholder's information. If it’s the same as yours, simply check the box provided.
5. Complete the Reason for Visit section by indicating if it relates to a work injury or an auto accident. Fill in any additional details as required.
6. If applicable, provide Responsible Party Information for minors or dependents. Include their name, relationship to patient, and contact information.
7. Finally, review all sections for accuracy before signing at the bottom of the form to consent to follow-up communication regarding your visit.

Start using our platform today to easily complete your Registration Form - Lansing Urgent Care online for free!