Patient Registration

Palm Beach Urgent Care

4714 Okeechobee Blvd
West Palm Beach, Florida 33409
Phone: 561 640 7505

In order to better care for you, we would like you to review the following pertinent information.

We will see you as quickly as we can but waiting time will vary depending on patient volume at any given time. Patients are generally seen in the order in which they signed in but occasionally, patients may be seen out of order at the discretion of the staff, if they have a condition that requires immediate attention – such as trouble breathing or extensive bleeding.

The staff will call you in and verify your medical history. Our policy is to take a complete set of vital signs on all patients.

Many, but not all, conditions or injuries can be treated in the Clinic. The practitioner will assess and treat you to the best of his/her ability in this setting. If you need an immediate referral, we will help arrange it for you if you desire. Any patients deemed critically ill will be transported to the nearest appropriate medical facility by ambulance.

IMPORTANT: FOR LIFE THREATENING EMERGENCIES SUCH AS CHEST PAIN OR LOSS OF CONSCIOUSNESS, ETC. GO IMMEDIATELY TO THE HOSPITAL EMERGENCY ROOM OR CALL 911.

I understand and agree to abide by Indian River Walk in Clinic’s policies. I agree/consent to be treated.

___________________________________Patient’s/Legal Guardian’s Signature ___________________________________Date

 

Patient information:

 

First Name:

Last Name:

Employer:

Contact Name:

 

Street Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

 

About Your Inquiry:

 

New Injury:

Date Of Injury:

Type Of Injury:

 

Payer/Carrier Information:

 

Payer/Carrier:

Claim Number:

 

Street Address:

City:

State:

Zip:

Phone:

Fax:

 

Description Of Services:

 

Drug Screen Required:

Drug Screen Type:

Reason:

DOT Testing Agency:

Alcohol Test:

Test Type:

Alcohol Source:

Physical:

If other Physical was selected, please explain:

Vaccinations:

If other Vaccination was selected, please explain:

Other Services:

 

Locations:

 

 4714 Okeechobee Blvd, West Palm Beach, FL 33463 M-F 7:30-Midnight Sat & Sun 9-5 11327 Okeechobee Blvd, Royal Palm Beach, FL 33411 M-F 8-5

 

Authorization:

 

Authorizing Person:

Phone:

Date Authorization Expires: (Required for Drug Screens):

 

I testify that the information in this form is accurate, and I authorize Coach Comp America to treat patient as requested above. (Enter your full name to "sign.")

 

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