Registration – #SOUTHERNFLARECARES

Southern Flare Urgent Care Center.

100 Timber Trail Rd. Richmond Hill, GA 31324

Telephone: (912) 445-5520

Patient Registration

Please Fill Out All Required Fields. Returning Patients Please Update Any Necessary Changes On This Page

Upload Photo ID and/or Insurance Card

Click or drag files to this area to upload. You can upload up to 4 files.

Save Time. Upload Photo ID (License) AND Insurance Card.

Did You Upload Photo ID and/or Insurance Card? *

Yes (Photo ID)
Yes (Insurance Card)
No
Both (Photo ID and Insurance Card)

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient's Date of Birth (DOB) *

Above the calendar, you can click or highlight the month and year to enter manually.

Sex *

Home Phone #

Cell Phone # *

Patient's Social Security # (SSN) *

Employer

Place of Employment

Pharmacy

Pharmacy of Preference, or for Patients Who Use Specific Pharmacy.

Is patient UNDER 18? If YES, enter Parent or Guardian info under Emergency Contact *

Emergency Contact *

First

Last

Emergency Contact # (XXX) XXX-XXXX *

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

*Enter address if emergency contact not in same home

Emergency Contact SSN

*if patient under 18

Emergency Contact Relationship *

Primary Insurance Company Name: *

VA Retiree Approved Center

Secondary Insurance Company Name:

VA Retiree Approved Center

Insurance Company Name: (if not listed)

Uninsured Patients please put SELF and leave the rest of boxes blank

Primary Insurance Policy # *

Secondary Insurance Policy #

Relationship to Insured *

Primary Policy Holder Name *

First

Last

Policy Holder Date of Birth (DOB) *

Above the calendar, you can click or highlight the month and year to enter manually.

Primary Policy Holder SSN *

Discount Code:

A Thank You For Registering Online. Southern Flare Cares. Don't forget to hashtag us!

Name

If Google reCAPTCHA Security finds entry error(s) for any reason, please RE-Upload Photo ID and/or Insurance as well. Security measures do not save your file uploads for your safety.