List all known allergies. If none enter "No Known Allergies".
Please list all prescriptions, non-prescriptions, vitamins, supplements dosages and how often
I give permission to Family First Urgent Care, its providers, affiliates, and medical personnel to provide medical services, including but not limited to x-rays, laboratory, administration of medications, anesthetics and any treatment recommended by the provider to me/child. I authorize Family First Urgent Care to disclose my current and previous medical records, consultation and treatment plans, to my referring physician, other healthcare providers, and hospitals that will participate in my care. I understand that by signing this form I am seeking medical care until I withdraw consent to Family First Urgent Care privacy officer in writing. This office Notice of Privacy Practices is available on our website (www.familyfirstuc.com). This explains how my protected health information (PHI) will be used and disclosed. I understand that I am entitled to receive a copy of this document at my request and authorize the use and distribution as described. I understand that this form is not electronically secure.
