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Patient Form

We ask that all patients complete this form online prior to check in. This will allow for a touch-free check-in process.

Please email your identification and insurance documents directly to

If you are completing this form for COVID testing we do NOT need your Driver’s License and Insurance as COVID testing is a cash-only service.


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    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

    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.


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    +1 850.231.1919

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    please dial 911.

    Fax: +1 850.231.1918