ACCU Clinic Registration Form

ACCU TESTING IS NO LONGER OPEN REGULAR HOURS. IF YOU NEED TESTING, PLEASE CONTACT US TO ARRANGE AN APPOINTMENT AT INFO@ACCUTESTINGCENTER.COM

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. *

I understand

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

Patient information

First Name * 🛈

Last Name *

Gender *

Street Address *

Apt

City *

State *

Zip Code *

Mobile Phone Number *

Email Address *

Date of birth (mm/dd/yyyy) * +

What are your symptoms? Check all that apply. *

When did your symptoms start? +

Which pharmacy would you like any prescriptions sent to? Please write the name and phone number

Have you been to Accu Testing or Accu Clinic before? *

Are you registering any more family members from the same household and with the same insurance? *

Please list all the family members names and dates of birth who need to be seen

+-

Do any patients have any food or medication allergies? *

What allergies? *

Insurance information (We collect insurance information which will be used for any diagnostic testing needed to be sent to our lab for processing)

Have you already provided us with current insurance information during a past visit? (If yes, won't need to collect it again, but please ensure previous information provided is still current).

Insurance company name * 🛈

Insurance company claims address 🛈

City 🛈

State 🛈

Zip Code 🛈

Patient ID * 🛈

Group number

Relationship to primary insured *

Add secondary insurance?

Yes

No

Fever or chills	Cough
Shortness of breath or difficulty breathing	Ear Pain
Headache	Loss of taste or smell
Sore throat	Mouth Sores or Lesions
Congestion or runny nose	Nausea or vomiting
Diarrhea	Other Other