LEARN ABOUT OUR COVID-19 OPERATIONAL CHANGES

Covina Urgent Care

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Registration Forms

Covina Urgent Care

Covina Urgent CareCovina Urgent CareCovina Urgent Care
Home
Services
insurance & Pricing
SCHEDULING
Contact Us
Registration Forms
More
  • Home
  • Services
  • insurance & Pricing
  • SCHEDULING
  • Contact Us
  • Registration Forms

  • Home
  • Services
  • insurance & Pricing
  • SCHEDULING
  • Contact Us
  • Registration Forms

Patient Registration Forms


All new patients must download, complete, and submit these forms before doing a telehealth or phone consultation.


Once you complete the registration forms email them to us at CovinaUrgentCare@gmail.com


To reduce your wait time for walk-in visits, email your forms to us before driving here, or print the forms and bring them in completed. 


New Patient Registration Fillable Form [English] (pdf)Download
Returning Patient Registration Fillable Form [English] (pdf)Download
New Patient Forms (Spanish) (pdf)Download
Returning Patient Forms (Spanish) (pdf)Download

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