Book an Appointment We are open Monday to Friday 8 am to 5 pm Patient Information Date: Time: 8 AM9 AM10 AM11 AM12 PM1 PM2 PM3 PM4 PM5 PM Patient Name: Date of Birth: Patient Email: How they Find Us: Address: Social Security Number: Sex: MaleFemale Driver License: Marital status: SingleMarrried Spouse's name : Emergency Contact: Insurance Information Primary Insurance : Secondary Insurance: Subscriber : Subscriber: Policy Number : Policy Number: Group Number : Group Number : Physician Information Primary Care Physician : Phone : Pharmacy Name : Allegies to Medication: Health Care Authorization Form Patient Name : Date: Patient SS : Date of Birth: The patient identified above, authorizesto use or disclose protected health information in accordance with the following Specific AuthorizationsI give permission to Urgent-Care on Wheels/ USMDDirect.com to verify my insurance, use my address, phone number, and clinical records to contact me with appointment reminders and missed appointments. I give permission to.Urgent-Care on Wheels/ USMDDirect.com to: Post my testimonialDisplay patient photographSend me a newsletterSend a birthday card or holiday related cards information about treatment alternatives or other health related information. If.Urgent-Care on Wheels/ USMDDirect.com contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail (Open Room Authorization - Optional) I give Urgent-Care on Wheels/ USMDDirect.com to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, the doctor will provide a room for these conversations. By signing this form you are giving.Urgent-Care on Wheels/ USMDDirect.com permission to use and disclose you protected health information in accordance with the directives listed above. Expiration- The authorization shall expire on the following date: The authorization is requested by.Urgent-Care on Wheels/ USMDDirect.com for its own use/disclosure of PHI. (Minimum standards apply) You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION,Urgent-Care on Wheels/ USMDDirect.com will not refuse to provide treatment I have read and received the Notice of Privacy Practices for Protected Health information Patient (Parent/Guardian) Full Name: Date: Payment Options Service Charge : $99 + PPO insurance Cash Price : $225 We accept PayPal, AmExp, Visa, Master card