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VISIT REASON
Patient Information
First Name
Last Name
Date of Birth
Phone
Email
Best way to contact youEmailTextVoice
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Urgent Care Details
Reason for Visit (check all that apply)Sprain/StrainBroken Bone (Closed Fracture)Joint Pain/SwellingSports-Related InjuryCast or Wound IssueNeck/Back PainHand/Wrist/Foot/Ankle InjuryOther
Briefly describe your injury or symptoms
Date of Injury (if known)
Is this a worker's comp injury?YesNo
How did the injury occur?
Are your symptoms worsening?YesNo
Current pain level (1–10)
Insurance, Prior Care & Consent
Insurance Provider
Member / Policy ID
I do not have insurance and am interested in self-pay / good faith estimate options.
Have you received care for this issue elsewhere?ERUrgent CareDoctorNone
Pharmacy Name & Location
I consent to Synergy Orthopedic Specialists contacting me to schedule and confirm appointments.
I acknowledge urgent care is for musculoskeletal injuries (not for medical emergencies or chest pain).
Workman’s Comp Details
Employer Name
Claim Number (optional)
Adjuster Contact Info
Date of Injury
Prior treatment for this work injury (if any)
Insurance & Consent
