Patient Information
First Name*:
Middle Name:
Last Name*:
Gender:
Select Gender
Female
Male
Contact Information
Contact Name (if different than patient name):
Address*:
City*:
State*:
AL
AK
AR
AZ
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
MH
NJ
MN
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code*:
Telephone*:
Email Address:
Insurance Information
Primary Health Insurance
Name:
Please Select
Aetna
Blue Cross/Blue Shield
Humana
Medicaid
Medicare
None
Other (specify below)
PacificCare
Self Pay (Private)
Unicare
Unknown
UT Select (Blue Cross/Blue Sheild)
(Please specify Other)
Primary Health Insurance
Type:
Select One
EPO
HMO
Medicaid
Medicaid HMO
Medicare
POS
PPO
Other
I Don’t Know
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):
Select One
EPO
HMO
Medicaid
Medicaid HMO
Medicare
POS
PPO
Other
I Don’t Know
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 Kendall Immediate Care?
Please Select
Yes
No
Do you have a particular physician that you would like to see?
Yes
No
If yes, please enter that physician’s name here:
Have you seen this physician before?
Please Select
Yes
No
Type of service requested:
Choose Service
Pediatric Allergy
Pediatric Cardiology
Pediatric Child Development
Pediatric Diabetes/Endocrinology
Pediatric ENT-Otolaryngology
Pediatric Gastroenterology
Pediatric Genetics
Pediatric Hematology/Oncology
Pediatric Infectious Diseases
Pediatric Nephrology
Pediatric Neurology
Pediatric Ophthalmology
Pediatric Orthopedics
Pediatric Special Services/Chronic Care
Pediatric Surgery
Adult Allergy
Adult Cardiology
Adult Dermatology
Adult Diabetes/Stark Center
Adult Endocrine
Adult Family Medicine
Adult Gastroenterology
Adult Geriatric
Adult Hematology/Oncology
Adult Infectious Disease
Adult Nephrology
Adult Neurosurgery
Adult OB/GYN
Adult OB/GYN Women’s Health Care Group
Adult Ophthalmology
Adult Oral Surgery (not routine dental)
Adult Orthopedic
Adult Otolaryngology (ENT)
Adult Pain Clinic
Adult Plastic Surgery
Adult Rehab OT/PT
Adult Surgery Clinic (Burns, Breast, Vascular)
Adult Urology
Adult Weight Loss Center
Reason for appointment:
Time Preference
Day of week:
Select Day
Any
Monday
Tuesday
Wednesday
Thursday
Friday
or
Second Choice (Optional)
Monday
Tuesday
Wednesday
Thursday
Friday
Time of day:
Select Time Preference
No Preference
Morning
Afternoon
Additional comments:
Your appointment will be made by the time you come into the office. For additional questions about your appointment, please call the Midwest Immediate Care 847-891-6850.