Online Patient Forms

Patient Registration Form

Please upload a photo of your driver’s license and health insurance card.

If you do not have health insurance, select the “I do not have health insurance.” to continue.

Please take a photo of the card on a flat surface with good lighting to get a clear picture to upload.

Only JPG, PNG, or PDF file formats accepted.

iPhone users NOTE: your model may not share photos in JPG format by default - please check your Share settings and turn on JPG sharing

Enter birth date as MM-DD-YYYY

Emergency Contact

First / Last Name
Spouse, etc.

Please list the person who will be responsible for any remaining bill

If 18 and under or if another person is responsible for remaining bill.

Required fields are highlighted with an asterisk. Once the required fields are filled in, a button will appear to proceed to the next form.

If a field is left blank, it will be highlighted in red.

Compass Urgent Care