New Patient

Welcome to FirstCare

Please complete the information below so we can prepare your chart before your appointment. Our front desk team will finalize any remaining details when you arrive.

Thank you for choosing FirstCare Urgent Care Center. Providing your information in advance allows us to create your chart ahead of time, so your visit can begin without delay.

Information collected online: patient demographics, contact details, emergency contact, preferred pharmacy, and the name of your insurance carrier.

Information completed at check-in: insurance card verification, medical history and current medications, and all required consent signatures. That includes Consent to Treat, the HIPAA Notice acknowledgment, our Financial Policy, and the optional AI Scribe consent. Completing these items in person keeps your medical and financial information secure within our office.

Prefer to complete the full registration packet in advance? Download the printable New Patient Registration Packet, complete it at home, and bring it with you.

English

New Patient Registration Packet (PDF)

Español

Registro de Nuevo Paciente (PDF)

What to Bring to Your Visit

A valid photo ID (driver's license, state ID, or passport)
Your insurance card (front and back)
A list of your current prescription medications and supplements
If the patient is a minor, a parent or legal guardian must be present

Patient Information

First Name *

Last Name *

Middle Initial

Date of Birth *

Sex *

Preferred Language

Home Address *

Apt/Unit #

City *

State *

ZIP Code *

Mobile Phone *

Home Phone

Email Address

OK to leave voicemail OK to text appointment reminders OK to email

Emergency Contact

Full Name *

Relationship to Patient *

Phone Number *

Preferred Pharmacy

Pharmacy Name

Pharmacy Phone

Pharmacy City

Insurance Carrier

Please provide the name of your insurance carrier only. Bring your physical insurance card with you so our team can verify your member ID, group number, and coverage details at check-in.

Primary Insurance Carrier

Secondary Insurance Carrier (if any)

Responsible Party (Guarantor)

Please complete this section only if someone other than the patient is financially responsible for the visit, such as a parent or legal guardian of a minor.

Guarantor Name

Relationship to Patient

Guarantor Phone

Guarantor Address

How Did You Hear About Us?

Referral Source

By submitting this form, you confirm that the information provided is accurate. Insurance verification, medical history, and all required consent signatures will be completed in person at your visit.

Questions Before Your Visit?

Give our front desk a call and our team will walk you through anything you'd like to know before you arrive.

Call (708) 265-2702 Save Your Spot