• / /
  • - -
  • ###-##-####
  • Physical Address
  • City, State
  • Zipcode
  • Preferred Pharmacy
  • For no medical history, write N/A
  • For no current medications write N/A
  • Responsible Party/Guardian
    (Please fill out if your child is a minor)

  • If same as patient, do not fill out the rest
  • / /
  • - -
    This waiver is specifically for online Urgent Care Services, which is a non-covered service for all Insurances. All patients that choose to have this procedure should know that it is not a medical necessity and it is completely voluntary. The charge for the online service will be $45 and it will be payed before the service can be rendered. I understand that I will be receiving health care services through interactive videoconferencing equipment. I understand that my privacy and confidentiality will be protected. When I am receiving services via online, I will be notified as to who is in the room at the remote site. The service is not a complete doctor visit and you will get a diagnosis to the best of the doctor's knowledge due to the circumstances. It is recommended that this service is only used when symptoms are not severe. If the provider recommends you to come in, no other fees other than the $45 will be charged as long as you come in within 12 hours. If you decide to come in another day, you will be charged for the Urgent Care visit on top of the online service. San Luis Walk-In Clinic is not responsible for poor internet connection or if the call is disconnected due to a poor internet connection.
    I acknowledge that I am signing this statement voluntarily and that it is not being signed under duress. I understand that by signing this form, I will be fully responsible for the total billed services for the above-said service and will pay the San Luis Urgent Care this amount, not my insurance. I understand that it is my choice to have these services provided at this time by this provider.

    San Luis Walk in Clinic shall ensure that:
    A patient is treated with dignity, respect, and consideration; A patient as not subjected to:
    Abuse; Neglect; Exploitation; Coercion; Manipulation; Sexual abuse; Sexual assault;
    Except as allowed in R9-10-1012(B), restraint or seclusion; Retaliation for submitting a complaint to the Department or another entity; or Misappropriation of personal and private property by an outpatient treatment center’s personnel member, employee, volunteer, or student; and
    A patient or the patient's representative:
    Except in an emergency, either consents to or refuses treatment; May refuse or withdraw consent for treatment before treatment is initiated; Except in an emergency, is informed of alternatives to a proposed psychotropic medication or surgical procedure and associated risks and possible complications of a proposed psychotropic medication or surgical procedure; is informed of the following: The outpatient treatment center’s policy on health care directives, and The patient complaint process; Consents to photographs of the patient before a patient is photographed, except that a patient may be photographed when admitted to an outpatient treatment center for identification and administrative purposes; and Except as otherwise permitted by law, provides written consent to the release of information in the patient’s: Medical record, or Financial records San Luis Walk in Clinic shall ensure that: A patient has the following rights:
    Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis; To receive treatment that supports and respects the patient’s individuality, choices, strengths, and abilities; To receive privacy in treatment and care for personal needs; To review, upon written request, the patient’s own medical record according to A.R.S. §§ 12-2293, 12-2294, and 12-2294.01; To receive a referral to another health care institution if the outpatient treatment center is not authorized or not able to provide physical health services or behavioral health services needed by the patient; To participate or have the patient's representative participate in the development of, or decisions concerning, treatment; To participate or refuse to participate in research or experimental treatment; and To receive assistance from a family member, the patient’s representative, or other individual in understanding, protecting, or exercising the patient’s rights.

    I authorize and consent, MyUCP licensed healthcare providers to examine my person, perform any medical diagnostics studies, and give medical treatment which is consistent with quality medical care.

    San Luis Clinic may provide, receive, or disclose the information to the following person, organization, or entity either verbally or in written as requested. It is hereby understood that this consent for disclosure is subject to revocation by the client at any time except to the extent that action has been taken on that consent. Without express revocation consent will expire after two months or when the patient terminates continuous treatment in the SLWIC system, whichever is later.
  • / /
  • After signing and hitting submit, you will be redirected to the waiting room where a provider will see you.