Burton Urgent Care Patient Registration Form

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Call 911 immediately if you are experiencing any of the following:
Severe Chest Pain
Severe Shortness of Breath
Uncontrolled Bleeding
Allergic Reaction
Any Other Life Threatening Condition

Reason For Visit / Symptoms(Required)

Type Of Visit(Required)

Work

Auto

Personal

Are you a smoker?(Required)

Yes

No

Sex(Required)

Female

Male

Patient's Name(Required)

First Middle Last

Patient's Date of Birth(Required)

Patient's Social Security Number(Required)

Patient's Phone(Required)

Patient's Email(Required)

Patient's Address(Required)

Street Address City State ZIP Code

Primary Care Physician(Required)

First Last

Primary Care Phone

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Relationship of Emergency Contact(Required)

Payment

Health Insurance

Auto Insurance

Employer

Self-pay

Other

Other Payment Option(Required)

Primary Insured Name(Required)

First Last

(Name on Insurance Card)

Primary Insured Date of Birth(Required)

Primary Insured Number Social Security(Required)

Primary Insured Sex(Required)

Female

Male

Primary Insured Address

Street Address City State ZIP Code

Primary Insured Phone Number

Primary Insured Cell Number

Primary Insured Work Phone

How did you hear about us?(Required)

Drive-by

Facebook

Mail

Google

Referred

Newspaper

Other

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1192 W Bristol Rd, Flint, MI 48507

HOURS:
MON-FRI: 9a-7p
SAT-SUN: 9a-3p

PHONE:
810-535-5530

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