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The clinic has reached its limit for this visit reason today.

Patient First Name

Patient Last Name

Visit Day

Visit Time

Cell Phone Number

Patient Type

Date of Birth

Patient Birth Sex

Chief Complaint:

Is this a telemedicine visit?

Reason for Telemedicine Visit (if applicable)

Are you or is a member of your family is an employee of LifeBridge Health?

Telemedicine Patients: I have reviewed Children's Urgent Care Center’s CUC Waivers.

Telemedicine Patients: I have reviewed ExpressCare Urgent Care Center’s waivers.

I understand that if I have a commercial Insurance, I will be asked to leave a card on file. View our full policy here.

I understand that IF I am an uninsured patient seeking COVID screening and testing, I meet the HRSA Criteria .

Reason for Today's Visit:

minutes before your visit