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STATED QUICK QUALITY URGENT CARE REGISTRATION FORM (Please Print) Today's date:Primary Care Dr.:PATIENT INFORMATION Patients last name:First:Is this your legal name? Middle:(Former Name) Mr. Mrs.

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Gather all necessary identification and insurance information.

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Arrive at the east 23rd urgent care location during their operating hours.

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East 23rd Urgent Care is a medical facility that provides immediate care for non-life-threatening conditions, offering services such as treatment for minor injuries, illnesses, and urgent medical needs without the need for an appointment.

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The purpose of East 23rd Urgent Care is to provide accessible and timely medical care for urgent health issues, helping to relieve pressure on emergency rooms and ensuring patients receive appropriate treatment quickly.

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Information that must be reported typically includes patient identification details, contact information, medical history, allergy information, and the specific issues or symptoms prompting the visit.

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