PATIENT INFORMATION FORM

Patient Information Form

Which location will we be taking care of you?

Anaheim - A&C Urgent Care

Cerritos - A&C Urgent Care

First name

Last name

Phone

Date of Birth

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Date and time

Month

Day

Year

Time

HoursMinutes

Reason for Visit

Insurance Card

Insurance ID

Signature of Consent

Signature field is empty.

I authorize treatment for myself and my children. Emergency treatment may be given in the event that children are brought in by any other person other than a parent. Use your mouse or finger to sign your signature.

Financial Responsibility

Signature field is empty.

I understand that I will be held responsible for payment of all services rendered. Use your mouse or finger to sign your signature.