Acworth Urgent Care - Patient Registration Forms & Privacy Notices

If you are a new patient, you can save time by filling out paperwork before you get here. Please print out the registration forms below, fill them out, and then bring them in when you come for your appointment.

Registration Forms for Acworth Urgent Care

Patient Registration Form

Patient Consent Form

Health History Form

Authorization for Release of Private Health Information (PHI)

Release of Information to Patient Representative

Autorización para el suministro de información

Other Forms

Georgia Sports Physicals Form

Flu Shot Information & Consent

Privacy Notices

This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Notice of Privacy Practices

Aviso Sobre las Practicas de Privacidad

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Get Acrobat Reader (this link opens a new browser window).


WE DO NOT HAVE FACILITIES TO TREAT LIFE THREATENING ILLNESS OR INJURIES
If you are experiencing symptoms of a true emergency, such as a chest or abdominal pain, headache, neck stiffness, difficulty breathing, dizziness, loss of consciousness, confusion, numbness, weakness, or major injuries, etc. -- PLEASE CALL 911 IMMEDIATELY.