AFTEROURS URGENT CARE PATIENT INFORMATION

DATE: _______________   REASON FOR BEING SEEN:_____________________________________________________________________________

PATIENT NAME: __________________________________________________________________  DOB: ___________________________________

ADDRESS: ________________________________________________________________________________ APT#: __________________________

CITY: ___________________________________________________        STATE: __________________________________ZIP: ____________________

CELL PHONE: __________________________ HOME PHONE: __________________________ SSN: _______________________________________

EMAIL: __________________________________________________________________________________________________________________

MARITAL STATUS: _______________ SEX (Circle one ):  Male  /  Female       PRIMARY LANGUAGE: _________________________________________

RACE: _____________________________ ETHNICITY: _____________________ HEIGHT:___________________  WEIGHT:____________________

MEDICATIONS: ___________________________________________________________________________________________________________

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)

Postcard

Local Event

Building Sign

ER

Online Search:

Other:____________________________________

Letter

Magnet

Friend/Family

Employer

Google

PCP:_____________________________________

Newspaper

Insurance

Pharmacy

Phonebook

Ask.com / yp.com / iTriage

Doctor (not PCP):___________________________

Radio

Billboard

Hotel

Groupon

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: _______________________________________________

EMAIL: __________________________________________________________________________________________________________________

Responsible party, or Guarantor Signature:

X                                                                          _______________________               _______ _____Date: ______________________________________