Schamburg Immediate Care

Appointment Form:

Patient Information
First Name*:
Middle Name:
Last Name*:
Gender:
Contact Information
Contact Name (if different than patient name):
Address*:
City*:
State*:
Zip Code*:
Telephone*:
Email Address:
Insurance Information
Primary Health Insurance Name:	(Please specify Other)
Primary Health Insurance Type:
Policy # :
Group # :
Primary Holder First Name:
Primary Holder Middle Name:
Primary Holder Last Name:
Primary Holder Name:
Insurance Claim Phone #:
Secondary Health Insurance Type (if any):
Policy # :
Group # :
Insurance Claim Phone #:
Appointment Information
Primary Care Provider or Referring Physician's Name:
Primary Care Provider or Referring Physician's Phone Number:
Have you ever had an appointment at Schaumburg Immediate Care?
Do you have a particular physician that you would like to see?
If yes, please enter that physician's name here:
Have you seen this physician before?
Type of service requested:
Reason for appointment:
Time Preference
Day of week:	or
Time of day:
Additional comments:
Your appointment will be made by the time you come into the office. For additional questions about your appointment, please call the Schaumburg Immediate Care at 847-891-6850.