TEXAS HILLS URGENT CARE CENTERS New Patient Registration

These forms will be submitted electronically to Texas Hills Urgent Care Centers. Upon arrival, a valid drivers license, military ID card, or other form of picture ID must be presented. If you wish to file insurance for your visit, you must present your most recent insurance card for verification of benefits. You will be held responsible for any copay, deductible or coinsurance amount your insurance policy dictates. You will sign these forms upon arrival to the clinic.

By selecting a time of approximate arrival to the clinic does not guarantee that you will be seen or taken back at that time. Patients are seen either as they arrive or based on severity of the illness or injury they are being seen for. However, filling out these forms in advance does expedite check in at the facility by about 15 minutes.

For any questions about costs of services or directions to the clinic, please call either 830-798-1122 for our Marble Falls office or 512-263-1600 for our Bee Cave office.

* Which facility do you plan to be seen at for this visit?

Please be sure to bring your insurance card to your visit so that it can be copied or scanned into your chart. A valid photo ID is required upon check-in at our offices for any online registration.

* Date you plan to visit

* Approximate time you plan to come in

* Reason for your visit today

* Is the reason for the visit work related?

Yes

No

* Is the reason for the visit a result of a motor vehicle accident?

Yes

No

* Are your symptoms related to a dental problem, toothache, or oral abscess?

Yes

No

Patient Information

* Last Name

* First Name

* Middle Initial

* Birthdate (M/D/Y)

Social Security #

* Gender

* Marital Status

* Race

* Ethnicity

* Preferred Language

* Home Phone

Cell Phone

* Email Address

* Street Address

* City

* State

* Zip Code

Mailing Address Info (if different)

* Employer Name

* Employer Phone

* Employer Address (street address, city, state and zip please)

* Preferred Method Of Communication:

Responsible Party Information

Same as Patient

Responsible Last Name

First Name

Middle Initial

Birthdate (M/D/Y)

Social Security #

* Home Phone

Cell Phone

Mailing Address

City

State

Zip Code

Relationship to Patient

Employer Name

Employer Phone

Employer Address (street address, city, state and zip please)

* Name of Emergency Contact

* Emergency Contact Phone #

* How Did You Hear About Us ?

Enter other referral source

* Indicates Response Required