top of page
A&C Urgent Care_edited.png
A&C urgent care (2).png

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
Date of Birth
Month
Day
Year
Multi-line address
Date and time
Month
Day
Year
Time
HoursMinutes
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

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.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

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

bottom of page