Pre-Register - Pioneer Urgent Care. We value your health and your time.

Pre-Register - Pioneer Urgent Care. We value your health and your time.

Emergency care

HOME | SERVICES | HOURS & LOCATION | CONTACT | PHYSICIANS | PRE-REGISTER

Please fill out the following fields completely:

Patient Information

Patient Last Name:
First Name:
Middle Initial:

Date of Birth:
SSN#:
email(Remains Private!):

Sex:	Male Female

Patient Address:
City:
State:	Zip:

Billing Address:
City:
State:	Zip:


Home Phone:
OK to leave message?	Yes No

Cell Phone:
OK to leave message?	Yes No

Business Phone:
OK to leave message?	Yes No

Marital Status:
Single	Married	Divorced
Widowed	Separated

Emergency Contact Person:
Phone:
Relationship:

Primary Care Doctor Name:
Phone:
Fax:
City:
State:	Zip:
Referring Physician:
Phone:

Pharmacy Name:
Pharmacy Location:
Pharmacy Phone:

Reason for your visit:

Who referred you to our center? How did you hear about us?
Friend or Relative	Newspaper	Radio
Drove Past	Yellow Pages	Insurance Co.
Physician:

Employment Information

Emploayer Name:
Patient Occupation:
Employer Address:
Employer City:
Employer State:	Zip:
Employer Phone:

Insurance Information

Are You Self Pay?

Yes No

If you have Private Insurance, please complete the following information:

Primary Insurance Information

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Insurance Co. State:	Insurance Co. Zip:
Policy Holder Name:
Relationship to Patient:
Policy Holder DOB:
Policy Holder SSN#:
Policy ID Number:
Group Number:
Effective From:	To:

Secondary Insurance Information

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Insurance Co. State:	Insurance Co. Zip:
Policy Holder Name:
Relationship to Patient:
Policy Holder DOB:
Policy Holder SSN#:
Policy ID Number:
Group Number:
Effective From:	To:

Workman's Compensation Claim?

Yes No

Auto Accident Claim?

Yes No

If you answered yes to either of the questions above, please complete the following information below:

Insurance Co. Name:
Insurance Co. Phone:
Insurance Co. Address:
Insurance Co. State:	Insurance Co. Zip:
Nurse/Case Manager Name:
Nurse/Case Manager Phone:
Claim#:
Date of Accident:
State of Accident:
Body Parts Injured:
Adjuster Name:
Adjuster Phone:
Adjuster Fax:

Past Medical History
High blood pressure		High cholesterol
Heart disease		Heart failure
Atrial fibrillation		Peripheral vascular disease
Hypothyroidism		Diabetes
Asthma		COPD
GERD		Gall stones
Inflammatory bowel disease		Stroke
Seizures		Cancer
Kidney stones		UTI
Chronic back pain		Tetanus vaccine within 5 yrs
Heart surgery		Tonsillectomy
Hysterectomy		Cholecystectomy
Orthopedic surgery

Social History

Employment:
full-time	part-time	unemployed
retired	disabled

Lives with:
alone	spouse	disabled spouse
child	other

Alcohol:
never	rarely
weekly	daily

Caffeine:
none	1-2 daily
3-5 daily	more than 5 daily

Smoking:
never smoked	former smoker	current smoker

Recreational drug use:
never	recovered	currently

Family History

Mother:
alive	deceased	cancer
heart disease	diabetes	stroke

Father:
alive	deceased	cancer
heart disease	diabetes	stroke

Siblings:
alive	deceased	cancer
heart disease	diabetes	stroke

Review of Symptoms
Weakness	Yes	No
Fever	Yes	No
Headache	Yes	No
Tingling numbness	Yes	No
Sore throat	Yes	No
Nosebleeds	Yes	No
Runny nose	Yes	No
Ear ache	Yes	No
Sinus pain/drainage	Yes	No
Cough	Yes	No
Shortness of breath	Yes	No
Chest pain	Yes	No
Palipitations	Yes	No
Leg edema	Yes	No
Nausea	Yes	No
Vomiting	Yes	No
Diarrhea	Yes	No
Constipation	Yes	No
Frequent urination	Yes	No
Pain with urination	Yes	No
Joint pain	Yes	No
Joint swelling	Yes	No
Muscle aches	Yes	No
Easy bruising	Yes	No
Swollen Glands	Yes	No
Vaginal discharge	Yes	No