Online Registration

If you are already a MedRite patient, you don't need to fill out the form below. Just walk in.

Patient Information

Emergency Contact

Authorize Release of Patient Health Information

If you would like to authorize the release of your health information, please specify to whom we may discuss it with.

Consent For Notification Of Test Results/Medical Information

I give permission to MedRite Urgent Care to

Other Information

I acknowledge that I have read the Notice of Privacy Practices