New Patient

Welcome to FirstCare

Fill out your patient information below to save time at check-in. Our front desk will finish the rest with you when you arrive.

Thank you for choosing FirstCare Urgent Care Center. Complete the form below so we can create your chart before you arrive.

What gets collected here: patient demographics, contact information, emergency contact, preferred pharmacy, and the name of your insurance carrier.

What we handle in person at check-in: insurance card scan and member ID verification, medical history and current medications, required consent signatures (Consent to Treat, HIPAA Notice, Financial Policy, and optional AI Scribe consent). This keeps your sensitive medical and financial details off the internet and secure inside our office.

If you'd rather bring the full packet already completed, download the printable New Patient Registration Packet (PDF), print it, complete it at home, and bring it with you.

What to Bring to Your Visit

Photo ID (driver's license, state ID, or passport)
Insurance card (front and back)
List of current prescription medications and supplements
If your child is the patient, the 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

Enter the name of your insurance carrier only. Please bring your insurance card to the visit so we can verify member ID, group number, and coverage at check-in.

Primary Insurance Carrier

Secondary Insurance Carrier (if any)

Responsible Party (Guarantor)

Complete this section only if someone other than the patient is financially responsible for this visit (for example, a parent or 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 the information above is accurate. Insurance card verification, medical history, and required consent signatures will be completed in person at your visit.

Questions Before You Come In?

Call our front desk and we will walk you through anything you need to know.

Call (708) 265-2702 Save Your Spot