ACCU Clinic Registration Form

Accu Clinic is for minor illnesses and ailments in both children and adults. Providers are onsite to offer examinations and also prescribe any medications or testing deemed neccesary during your visit. Accu Clinic does NOT bill insurance for provider visits or any rapid testing (only overnight testing can be billed to insurance). You will be provided with documentation which can be submitted to your insurance company for reimbursment. However, we are unable to offer any guarantees that you will be reimbursed as each insurance is different.
If you are not looking to see a provider and are just trying to access Accu Testing, please click here and you will be directed to the appropriate registration page. *

All information is kept strictly confidential and is only shared as required by law.

Patient information

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What are your symptoms? Check all that apply. *
 
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Please list all the family members names and dates of birth who need to be seen
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Insurance information (We collect insurance information which will be used for any diagnostic testing needed to be sent to our lab for processing)

Add secondary insurance?