Patients Name(required) Warning Sex Male Female Warning Home Phone Warning Cell Phone Warning Work Phone Warning May we call you at home? Yes No Warning May we call you at work? Yes No Warning May we leave a message? Yes No Warning Email(required) Warning Address Warning City Warning State Warning Zip Code Warning Date of birth (YYYY-MM-DD) Warning Social Security Number Warning Drivers License Number Warning Occupation Warning Employer Warning Employers Address Warning Primary Care Physician Warning Primary Care Physician Phone Warning Preferred Pharmacy Warning Preferred Pharmacy Phone Warning Emergency Notification Name Warning Relationship Warning Address Warning City Warning State Warning Zip Code Warning Emergency Phone Warning Spouse Information Name Warning Social Security Number Warning Date of birth (YYYY-MM-DD) Warning Employer (Company, City) Warning Spouse Phone Warning Insurance Information Primary Plan Warning Address Warning City Warning State Warning Zip Code Warning ID Number Warning Group Name Warning Group Number Warning Co Pay Amount Warning Effective Date (YYYY-MM-DD) Warning Secondary Plan Warning Address Warning City Warning State Warning Zip Code Warning ID Number Warning Group Name Warning Group Number Warning Co Pay Amount Warning Effective Date (YYYY-MM-DD) Warning Guarantor/Insurance Policy Holder Name Warning Address Warning City Warning State Warning Zip Code Warning Employer Name Warning Employer Address Warning City Warning State Warning Zip Code Warning Relationship to patient Warning General Payment in full is due at time of visit. We will be happy to file your insurance for reimbursement, if we are participating with the plan. It is your responsibility to be aware of coverage limits on your insurance plan. If you have any questions regarding your insurance coverage of payment, you must contact the insurance company directly. AUTHORIZATION FOR TREATMENT: I consent to examination, treatment, and any procedures including emergency treatment deemed necessary and ordered by our physicians and I am personally responsible for any charges. AUTHORIZATION FOR INSURANCE: I authorize release of any information concerning myself or my child to my insurance company regarding treatment for services covered by my insurance plan. AUTHORIZATION TO CONTACT ME: I hereby acknowledge that Amarillo Urgent Care may contact me, either by phone, email, or mail to provide a reminder of an appointment, gather demographic or insurance information, or to inform me of services or events offered at the facility. ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE: I hereby acknowledge that Amarillo Urgent Care has provided me a copy of their Privacy Notice. I understand that I am legally responsible for payment of all bills for care given by Amarillo Urgent Care to myself or any of my dependents, regardless of insurance reimbursement. Patient or Responsible Party signature Signature Warning Date (YYYY-MM-DD) Warning Warning. SendSubmitting form Δ