• Email Us: care@aextensiveurgentcare.com
  • Call Us: (310) 910-0660

Contact Info

Patient Forms

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Patient Forms & Documents

To expedite your check-in process, we recommend downloading and completing the following forms before your visit to A Extensive Urgent Care. Please bring your completed forms along with your ID and insurance card.

Forms are provided in PDF format. To view and print these forms, you will need Adobe Acrobat Reader, which can be downloaded free from Adobe's website.

New Patient Registration Form

Basic information, medical history, and insurance details for new patients.

Download PDF

Medical History Form

Detailed health history including allergies, medications, surgeries, and chronic conditions.

Download PDF

HIPAA Consent Form

Authorization for use and disclosure of protected health information.

Download PDF

Insurance Information Form

Details about your insurance coverage, policy numbers, and subscriber information.

Download PDF

Assignment of Benefits Form

Authorization for direct payment from your insurance company to A Extensive Urgent Care.

Download PDF

COVID-19 Screening Form

Pre-visit screening for COVID-19 symptoms and exposure risk assessment.

Download PDF

Additional Forms

The following forms may be required for specific services:

  • Sports Physical Authorization Form Download
  • Minor Consent Form (for unaccompanied minors) Download
  • Medication Refill Request Form Download
  • Medical Records Release Authorization Download

Visit Reminders

  • Complete forms before arrival
  • Bring valid photo ID
  • Bring your insurance card
  • Bring list of current medications
  • Arrive 15 minutes before appointment
  • Wear a mask per current guidelines

Need Help?

If you have questions about these forms or need assistance, please contact our patient services team:

  • (310) 910-0660
  • forms@aextensiveurgentcare.com

Our staff is available during regular business hours to assist you.

Book Your Appointment

Skip the wait by scheduling your visit in advance.

Book Now

Patient Portal Access

Access your health records, lab results, and communicate with our healthcare team through our secure patient portal.

  • View your visit history and upcoming appointments
  • Check lab and test results
  • Message your provider
  • Request prescription refills
  • Update your personal information
Access Patient Portal

New users: Please call our office to register