Medcove Urgent Care

Select Gender *

Male

Female

Other (list below)

Other

Address

Street Address *

City *

State *

Country

Postal code *

Occupation *

Emergency Contact Relationship *

Primary Care Physician *

Is patient under 18 years old? *

Yes

No

Parent/ Guardian Name (Responsible Party for Financial Obligations)

If patient is under 18, parent/guardian is also the financial responsible party

Please list ALL medications (prescription and non-prescription) that you take. (Include herbal remedies, vitamins, over the counter, street drugs, prescriptions etc.) *

Please list all current/prior illnesses/injuries and year of onset *

Please list all past surgeries *

Are any of your injuries related to a car accident? *

Yes

No

Are any of your injuries sustained from a work related injury? *

Yes

No

Please list all known allergies (e.g., medications, foods, environmental) and describe the reactions they cause

Do you smoke? *

Yes

No

Social Security # *

Consent, Privacy, and Financial Responsibility Acknowledgment

Terms and Conditions *

I have read, understood, and agree to the Consent, Privacy, and Financial Responsibility Agreement.

*If the patient is under 18, a parent or guardian must upload a valid ID along with the patient's insurance card

Please upload a photo or copy of driver's license or legal ID *

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? *

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

Patient Signature *

Clear