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:

Day:

Year:

Phone: *

Email:

Address: *

City: *

State: *

Zip Code: *

Contact Information : Step 2 - 4

Patient under 18:

Parent Name:

Parent Phone:
same as patient:

Date Of Birth:

Month:

Day:

Year:

Emergency Contact:

Last Name:

First Name:

Cell Phone:

Next of Kin:

Last Name:

First Name:

Cell Phone:

Insurance Information: Step 3 of 4

Insurance Carrier:

Policy#:

Group:

Include photo of insurance card:

Secondary Insurance Carrier:

Policy#:

Group:

Include photo of insurance card:

HBS Notice (for Medicare & Medicare Advantage)
a hardcopy is available at front desk.

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:

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:

Consent Required

Please proceed inside to see a registrar..

Mobile Urgent Care Check-In

Personal Information: Step 1 of 4

Contact Information : Step 2 - 4

Emergency Contact:

Next of Kin:

Insurance Information: Step 3 of 4