Register | First Choice Urgent Care

The quality care you receive at First Choice Urgent Care is second to none. We take great pride in knowing that all of our staff is highly dedicated to your continued well being.
We value your time. Below you will find our current estimated wait time so you can better plan your care today. Make sure to check out our Health News for great tips on keeping a healthy lifestyle.

15 minutes

(352) 332-1890

128 Northwest 137th Drive
Newberry, FL 32669

Mon - Fri    8:00 a.m. - 8:00 p.m.
Sat   9:00 a.m. - 4:00 p.m.
Sun   9:00 a.m. - 2:00 p.m.

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Medical Questionnaire - New Patients

* Required Fields.

Male Female

Health/Medical History Please check any that apply to your health history
Asthma Rheumatic Fever Arthiritis
Prostate Problems Cancer/Tumors Pneumonia/Lung Disease
High Blood Pressure Head Injuries Chicken Pox
Back Strain/Injuries Hearing Problems Freq. Headaches
Ulcers Hay Fever Thyroid Problems
Skin Disorders Herniated Disc Received Blood/products
Diabetes Blood Clots Kidney Stones
Gout Broken Bones Hormone Problems
Nervous/Mental/Emotional Problems Vision Problems Heart Problems
Hernia Sinus problems Syphilis
Amputations Spinal Injuries Ear Infections
Seizures/Convulsions Kidney Problems Positive TB test
Dizziness/Fainting Urinary problems

AUTO W/C Self Pay Private Insurance
BCBS United Medicare Avmed Aetna Cigna
Allied Humana Tricare




* Authorization for treatment- I voluntarily consent to the administration & cost of medical & surgical procedures, x-ray, and medication information for all services for myself on my dependents.
* Assignment of Insurance benefits: I authorize payment directly to 1st Choice Urgent Care for all benefits & the release of medical information for all services & payments otherwise payable to me.
* Release of Records: I authorize 1st Choice ICC to release (verbal or in writing) confidential medical information to any person or entity including my insurance carrier, employer if treatment is related to employment purposes, or other health care operations, which may be liable to me or my practitioner for charges for this treatment & quality management, utilization review, transfer, and follow up care.
* I understand I am financially responsible & agree to pay for all of the charges that are not paid or billed to insurance or any other third party payer. I understand that I must pay in full today for all services rendered unless my insurance is accepted. I must pay all applicable insurance co pays, coinsurances, and deductibles today.
* Receipt of Privacy Practices: I acknowledge that I have received and read the 1st Choice ICC notice of privacy practices.
* I acknowledge receipt of the notice of privacy rights with detailed information about how 1st Choice ICC may use and disclose my protected information.