Registration Forms

You can print the necessary forms below and fill them out before coming into the the office to save you time.

All files are in PDF format:

Release of Information

Patient Information

Informed Consent to Routine Procedures/Treatments

Privacy Notice Acknowlegement

Responsible Party for Payment

When you visit a our clinic, please be prepared to provide the following information:

  1. Patient and policy holder name, social security number, date of birth, address and telephone number.
  2. Whether you have been a patient before.
  3. Current insurance card.
  4. Your co-payment or deductible amount, if applicable, is due at the time of service.
  5. Your primary care physician’s name.
  6. List of your current medications and med allergies.

This information is needed to expedite your registration and to assist us in understanding the urgency of your visit. Thank you for choosing 99W Urgent Care for your healtcare needs.