Registration

Name (First, Middle, Last)
Date
Date of Birth
Address (Street and Zip Code)
Phone
Sex
Employer
How did you hear about us?
Primary Care Physician
Email
Name On Insurance Card
Person Responsible For Bill
Insurance ID #
Group #
Employer
Last 4 digits of SSN
BY CLICKING THE "SUBMIT" BUTTON, YOU ARE AGREEING TO ALL OF LIFETIME URGENT CARE, PLLC TERMS AND CONDITIONS.  YOU ARE ALSO AUTHORIZING LIFETIME URGENT CARE, PLLC TO USE YOUR INFORMATION AS NEEDED TO BILL, TREAT, AND/OR PROVIDE ANY OTHER HEALTH CARE TASKS.  LIFETIME URGENT CARE, PLLC WILL NEVER SHARE OR SELL YOUR INFORMATION TO A THIRD PARTY WITHOUT YOUR CONSENT.  YOU MAY REQUEST A FULL COPY OF OUR HIPPA POLICY AND/OR PRIVACY STATEMENT AT ANYTIME.