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Patient Forms

General Information

When you visit a Lourdes After Hours clinic, please be prepared to provide the following information:

  • Whether you have been a patient before
  • Patient and policy holder name, social security number, date of birth, address and telephone number
  • Picture ID
  • Current insurance card
  • Your co-payment or deductible amount, if applicable, is due at the time of service
  • Your primary care physician's name
  • List of your current medications

This information is needed to expedite your registration and to assist us in understanding the urgency of your visit. Thank you for choosing Lourdes After Hours for your healthcare needs. 

Maps Chief Complaint Consent Form Download Maps Notice of Privacy Practices Download Maps Patient Registration Information Download Maps Patient Rights & Responsibilities Download