New Patient – Appointment Registration Form

Patient Information

This information will be sent to your provider and will be kept as part of your patient records.

Appointment Information & Medical History

Insurance information

Only fill out this section if you are subscribed with any insurance company

Insurance information

In case of emergency

Financial Agreement

The above information is true to the best of my knowledge. I understand and agree that I am ultimately responsible for the balance for myself and all my identified children under 18 years of age as listed above for any professional services rendered. I understand and agree that I am responsible to pay any co-pays at the time of the service. Should my insurance claim be denied for lack of eligibility or termination of coverage, I understand that I will be held responsible and intend to make payment in full to Forme Rehabilitation, Inc. dba Forme Urgent Care and Wellness Center. I acknowledge that I will be billed for my deductible and/or coinsurance by Forme and hereby agree to make such payment upon receipt of bill.

IMPORTANT READ - INSURED PATIENT:

There will be a $25 fee for any missed visits for primary care and $50 fee for Specialties if you do not notify us at least 24 hours prior to your scheduled appointment time.

IMPORTANT READ - SELF PAY PATIENT:

As a self-pay patient, I understand that I will be responsible for payment of all lab work and will be billed separately by Quest Diagnostics. There will be a $25 fee for any missed visits for primary care and $50 fee for Specialties if you do not notify us at least 24 hours prior to your scheduled appointment time.