New Patient Registration "*" indicates required fields Today's Date* Month Day Year Selected Clinic*Urgent Care of BerwickUrgent Care of SandflyUrgent Care of Wilmington IslandPatient's DOB* Month Day Year Patient's Age*Patient's Gender*Patient's Name* First Middle Last Social Security Number*Patient/Guardian Email Address* Enter Email Confirm Email Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell Phone*Work PhoneEmployer*if none, type noneRace/Ethnicity*Check all that apply Asian Black/African American White/Caucasian Hispanic/Latino(a) Native American or Alaskan Native Native Hawaiian or Pacific Islander Other Unknown Prefer Not to Answer Marital Status*SingleMarriedDivorcedWidowedSeparatedDomestic PartnershipPrimary Care Physician*Primary Care Physician's Phone*Emergency Contact* First Last Relationship to Patient*Emergency Contact's Phone Number*Emergency Contact's Email Insurance InformationAre you submitting insurance information?*YesNoFront of Card*Max. file size: 100 MB.Back of Card*Max. file size: 100 MB.Primary Insurance*Subscriber's Name* First Last Subscriber's DOB* Month Day Year Subscriber's SSN*ID #*Group #*Do you have secondary insurance?*NoYesSecondary Insurance Front of Card*Max. file size: 100 MB.Secondary Insurance Back of Card*Max. file size: 100 MB.Secondary Insurance*Secondary Subscriber's Name* First Last Secondary Subscriber's DOB* Month Day Year Subscriber's SSN*Secondary ID #*Secondary Group #*Reason for VisitPlease describe the reason for today's visit*Were you involved in an accident?*NoYes. Worker's Compensation AccidentYes. Motor AccidentWere you injured as a result of this accident?*NoYesDate of Accident* Month Day Year If you were injured on the job, please have your employer complete the Workers Compensation Form. Would like us to contact your employer?*NoYesEmployer's Name* First Last Employer's Phone*Employer's Email* Your Name (Patient or Responsible Party)* First Last Relationship to Patient*if you are the patient, type "self"Patient Signature or Signature of Responsible Party*Today's Date* Month Day Year EmailThis field is for validation purposes and should be left unchanged.
