AFTEROURS URGENT CARE PATIENT INFORMATION
DATE: _______________ REASON FOR BEING SEEN:_____________________________________________________________________________
PATIENT NAME: __________________________________________________________________ DOB: ___________________________________
ADDRESS: ________________________________________________________________________________ APT#: __________________________
CITY: ___________________________________________________ STATE: __________________________________ZIP: ____________________
CELL PHONE: __________________________ HOME PHONE: __________________________ SSN: _______________________________________
MARITAL STATUS: _______________ SEX (Circle one ): Male / Female PRIMARY LANGUAGE: _________________________________________
RACE: _____________________________ ETHNICITY: _____________________ HEIGHT:___________________ WEIGHT:____________________
DOCTOR/PCP NAME & ADDRESS: _____________________________________________________________________________________________
PHARMACY NAME & ADDRESS: ______________________________________________________________________________________________
ALTERNATIVE/EMERGENCY CONTACT: _________________________________________________ PHONE: ________________________________
PERSON(S) WE MAY SPEAK WITH REGARDING YOUR CARE OR BILLS: ________________________________________________________________
We may share (Circle all that apply): Billing Information / Health Information
Via: Phone:____________________________ Email: ________________________________________________ Other:_______________________
1st INSURANCE NAME & SUBSCRIBER: _______________________________________________________________________ (Card Copy Required)
2nd INSURANCE NAME & SUBSCRIBER: _______________________________________________________________________ (Card Copy Required)
How did you hear about AfterOurs Urgent Care? (please circle all that apply)
Ask.com / yp.com / iTriage
Doctor (not PCP):___________________________
FindUC.com / Yelp
FINANCIAL: If you cannot pay balance in full within 60 days you must call (888) 541-3432 to be considered for any special arrangements. Accounts
without special arrangements that are not paid in full within 60 days will be turned over to a 3rd party collection agency. Accounts sent to
collections will receive a $75 collection fee to cover the cost for such actions and will receive negative activity on their credit report if left unpaid.
Cancelled checks and checks returned for insufficient funds will be assessed a service charge of $50.
CONSENT TO TREAT: I voluntarily consent to medical treatment and procedures that may be performed on me during this visit. This includes, but
is not limited to, medical, therapy, surgical care, x-rays, tests, medications, laboratory test(s), or other services, which may be ordered by a physician
participating in my care.
COMMUNICATION: By providing AfterOurs, Inc. with your landline or cell phone number(s), you give express authorization to contact you at these
numbers. This is to be in effect for all medical information/results from today forward unless otherwise specified by you, the patient.
ASSIGNMENT OF INSURANCE BENEFITS, PAYMENTS, AND RELEASE OF MEDICAL RECORDS: I hereby authorize payment of medical benefits to
AfterOurs Urgent Care. I further authorize the release of any medical/surgical information necessary for determining the extent of third-party
coverage and for processing an insurance claim on my behalf. I permit a copy of this authorization to be valid as the original. I understand that I am
ultimately responsible for and agree to pay all charges and expenses of the clinic for services and supplies furnished to me which are not paid
through benefits for prepaid healthcare, insurance plans, or medical assistance.
I, the undersigned, acknowledge that the information I have provided above is accurate to the best of my knowledge. I have read and
understand the above mentioned policies. Also, I understand and accept the HIPAA Privacy Practice of AfterOurs, Inc. as well as the Financial
Policy Explanation & Patient Agreement which is available in any of the AfterOurs clinic locations and at www.afteroursinc.com.
Patient Signature: X _ ______________ _____________ Date: ____________________
If person signing this document is not the patient being seen, please complete the following:
Responsible Party **Responsible party please provide current address if different from patient!**
PRINT NAME: ___________________________________________________________ SSN: ___________________________ DOB:_____________
ADDRESS: _____________________________________________________________________________________ APT#: _____________________
CITY: _________________________________________________________ STATE: ____________________________ ZIP: ____________________
CELL PHONE: _________________________________________________ HOME PHONE: _______________________________________________
Responsible party, or Guarantor Signature:
X _______________________ _______ _____Date: ______________________________________