Your Name (required)
Your Email (required) Telephone Date of Birth Address Medications Allergies If you are a new patient or your insurance has changed, please email a photo of your Driver’s License and the front/back of your insurance card to [email protected]
Consent By checking this box, I consent to treatment by Doc Smiley's Urgent Care. Email Consent By checking this box, I consent to receive lab results by email. HIPAA Privacy Disclosure By checking this box, I acknowledge the privacy policies (HIPAA). If you would like a copy you may request one.
Like us on Facebook
Follow us on Instagram