CARE PROGRAM Patient Appointment Request 
Comprehensive Addiction Recovery Education Program.

 At The Urgent Care, we know the journey to recovery can be very challenging. Our qualified, caring team is here to help you or your loved ones navigate the difficult road ahead. We are always accepting new patients and look forward to helping you in your recovery journey. 

Fill out this form to request an appointment in our CARE Program. Our team will promptly contact you for more information and to schedule your first visit with us.  

Text or call (504)291-4148 to contact our CARE Program Team directly. 
Sign in to Google to save your progress. Learn more
Have you been a patient in our CARE Program before? *
First Name *
Last Name *
Address/City  *
Preferred Location
Clear selection
Phone Number  *
Date of Birth *
Insurance Company *
Insurance Member ID
What drugs are you currently using?   *
Are you currently taking any Benzo's? 
(Klonopin , Xanax, Valium, Ativan, etc.)
Are you currently on any of the following Medications? *
If Yes to Suboxone or Subutex.
Are you getting them from a Doctor or Program?
Name of Doctor or Program (if yes above) 
Please list out any other medications that you take daily? Example:  hydrochlorothiazide - High Blood Pressure *
Do you drink alcohol? *
Any chance you could be pregnant?  *
If YES, to the above question. 
When is your due date?
Do you have reliable transportation to make it to your appointments? Select all that apply.

*Monthly appointments are required once established 
How did you hear about us?  *
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Urgent Care. Report Abuse