In effort to minimize time needed to complete your office registration we have supplied the Urgent Care forms. It is in editable PDF format and could be filled out using a compatible web browser or Adobe Acrobat Reader. Get Adobe Acrobat Reader
For New Urgent Care Patient:
We want your to visit to be as convenient as possible.
Please bring with you:
- Driver’s license or Photo ID
- Insurance Information
- Payment for co-pay or self-pay
- List of medications, allergies, past surgeries
Download Forms
EMR Registration (English).pdf
EMR Registration (Espanol).pdf
For Employee Urgent Care Patient:
Please bring the following:
- Filled out Authorization Slip Form
- Filled out Medical Examination Report Form (For DOT only)
- Filled out History of Work-Related Accident Form (Spanish / English)
- Filled out UCC-Physical Examination Form
Download Forms
Authorization Slip.pdf
History of Work Related Accident.pdf
Historia De Accidente De Trabajo.pdf
UCC – Physical Examination Form.pdf
Medical Examination Form (DOT only)
Urgent Care Email address: gatewayurgentcaremanager@pmcamd.com