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UCR logoUrgent Care Registration

Instructions for Patients

You may fax us your information by using the fax cover sheet enclosed. Please be sure that you fax to the correct location.
Do not email your patient information; we will not accept it in this format.

We will hold your information so that when you present to urgent care, your registration will be much quicker. You must come to the clinic on the same day you fax the forms and your signatures must be original (no fax signatures accepted). All faxed information will be destroyed at the close of day and will not be kept for future visits to urgent care.

  1. Fax Cover Sheet
  2. Patient Registration
  3. Medical History
  4. Consent to Treatment and Financial Policy
  5. Parental Consent for a Minor
Satisfaction survey
Picture of the Urgent Care facility in Chandler.
UCR logo Picture of the Urgent Care facility in Chandler.
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