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Consent Required
Please proceed inside to see a registrar..
If you have any questions, please call the Urgent Care desk at 518 580-2224
Mobile Urgent Care Check-In
Personal
Contact
Insurance
Verification
Personal Information:
Step 1 of 4
Do you consent to treatment?
Yes
No
Do you agree with the Financial Agreement?
Yes
No
First Name:
*
Last Name:
*
Date Of Birth:
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day:
01
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04
05
01
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31
Year:
2023
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2012
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1931
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1928
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1925
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1922
1921
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1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Phone:
*
Email:
Address:
*
#:
City:
*
State:
*
Zip Code:
*
Cancel
Next
Contact Information :
Step 2 - 4
Patient under 18:
Parent Name:
Parent Phone:
same as patient:
Date Of Birth:
Month:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day:
01
02
03
04
05
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year:
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Emergency Contact:
Last Name:
First Name:
Cell Phone:
Next of Kin:
Last Name:
First Name:
Cell Phone:
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Next
Insurance Information:
Step 3 of 4
Insurance Carrier:
Policy#:
Group:
Include photo of insurance card:
Capture Front
Capture Back
Secondary Insurance Carrier:
Policy#:
Group:
Include photo of insurance card:
Capture Front
Capture Back
HBS Notice (for Medicare & Medicare Advantage)
a hardcopy is available at front desk.
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Next
Verify Information
Personal Info
Name:
DOB:
Address:
Phone:
Email:
Parent Info
Parent Name:
Parent DOB:
Parent Phone:
Emergency Contact
Name:
Phone:
Next of Kin
Name:
Phone:
Primary Insurance
Carrier:
Policy#:
Group:
Card Photo:
Secondary Insurance
Carrier:
Policy#:
Group:
Card Photo:
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Submit