Walk-In Clinic & Urgent Care Locations

Date of Birth

Please Enter Patient's Date of Birth

Mobile

Please enter Patient Mobile Number in this format 555-555-1212

Insurance Carrier

Insurance Plan Name

Please specify your insurance plan

Upload Insurance Photos Front Back

Insurance Group Number

Insurance Member Id

Cardholder Name

Cardholder Date of Birth

Please Enter Cardholder Date of Birth

Cardholder Birth Sex

Female Male Other

Patient's Relationship to Insured

Read and review patient consent forms

By signing, I understand and agree to the terms and conditions contained in the forms above and agree to sign them electronically.

Please Read and Consent To Conditions for Treatment & Financial Disclosures

I agree to the Indigo Online Care Terms of Use and Privacy Policy

Please agree to Terms and Privacy Policy

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