UrbanCare, LLC

Patient Registration Form

Patient Information
Phone Numbers *   
Marital Status   


Preferred Contact Method *  

Race/Ethnicity (check all that apply)   

Do you have an Advanced Directive (DNR, Living Will)? *  

Employment Information
(Parent or Guardian employment if patient is a minor)
Responsible Party Information
(If the patient is a minor, the person responsible for the child completes the following)
Relation to the Child   

Insurance Information
Do you have Healthcare Insurance?   
Emergency Contact
Phone Numbers *   
Release of Authorization/Assignment of Benefits/Consent for Treatment
I authorize the release of any medical information necessary to process my insurance claim(s) or as needed by my insurance carrier. I authorize and request payment of medical benefits directly to UrbanCare, LLC. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me. I agree that a photocopy of this form may be used in place of the original.

I also consent for treatment for myself (any minor children in my care) by UrbanCare, LLC. I have reviewed the above information and to the best of my knowledge it is correct as written. I hereby agree to the Release of Authorization/Assignment of Benefits.
Patient or Representative Signature *– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
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