TEXAS HILLS URGENT CARE CENTER DISCOUNT CARD APPLICATION (1 Year Registration)

Please be sure to bring your DISCOUNT CARD every visit. A valid photo ID is required upon check-in at our offices in order to use the card at any time. Payment is due at the time services are rendered. Membership payment must be current on the date of service to receive benefits.

Member Information (Head of Household)

* Last Name

* First Name

* Middle Initial

Who is the Discount Card for?

* Email address (required as billing for monthly membership dues is delivered via email ONLY)

* Birthdate (M/D/Y)

Social Security #

* Gender

If married, name of spouse

* Home Phone

Cell Phone

Medical Discount Cards are only mailed to Austin or Hill Country addresses.

* Street Address

* City

* State

* Zip Code

Mailing Address Info (if different)

* Employer Name

* Employer Phone

Spouse Information

Spouse's Last Name

First Name

Middle Initial

Birthdate (M/D/Y)

Social Security #

Cell Phone

Employer Name

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

Dependents (under 18) if any

Last Name

First Name

Middle Initial

Birthdate (M/D/Y)

Gender

Last Name

First Name

Middle Initial

Birthdate (M/D/Y)

Gender

Last Name

First Name

Middle Initial

Birthdate (M/D/Y)

Gender

Last Name

First Name

Middle Initial

Birthdate (M/D/Y)

Gender

* Name of Emergency Contact

* Emergency Contact Phone #

* How Did You Hear About Us ? If an Employee of THUCC referred you, please list their name in the OTHER box so that we may thank them.

Enter other referral source

* Indicates Response Required