MedCove Urgent Care
Patient First Name
*
Patient Last Name
*
Date of Birth
*
Your Phone
*
Has your emergency information changed since your last visit?
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Yes
No
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relationship
Reason for your visit
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Personal Illness/Injury
TB Test
Motor Vehicle Accident
IV Hydration
Other
Have there been any changes to your medical history or medications since your last visit?
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Yes
No
New/Changed Medical Conditions
New/Changed Medications
Please list all known allergies (e.g., medications, foods, environmental) and describe the reactions they cause
Please upload a photo or copy of the FRONT of the patient's health insurance card
Please upload a photo or copy of the BACK of the patient's health insurance card
Do you have secondary health insurance?
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Yes
No
Please upload a photo or copy of the FRONT of the patient's secondary health insurance card
Please upload a photo or copy of the BACK of the patient's secondary health insurance card
Consent, Privacy, and Financial Responsibility Acknowledgment
Terms and Conditions
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I have read, understood, and agree to the Consent, Privacy, and Financial Responsibility Agreement.
Patient Signature
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Clear
Submit