Check-in to Northwest Urgent Care - Ina, Northwest Urgent Care - Ina

Appointment Type

Urgent Care

Projected Treatment Time

Thursday, April 3 at 11:30 am

Reason for visit * ( Max length 250 )

Referring Physician

Has the patient visited Northwest Urgent Care - Ina before? *

Does the patient have a primary care doctor? *

Patient's Health Insurance Plan *

Patient's Insurance Member Number

Patient's Insurance Group Number

Email Address *

We need your email address to send you the details of your visit. This email also includes cancellation instructions. No spam, we promise.

Patient's First Name * (Legal Name)

Middle Initial

Patient's Last Name *

Date of Birth *

Phone Number *

Gender *

Address *

Address Line 2

City *

State*

Zip Code*

Contact Name (if different from patient)

Terms and Conditions

I have read and agree to the InQuicker Online Scheduling terms of use. *
I have read the when to call 911 guide and understand that Online Scheduling is not to be used for life-threatening, debilitating, or emergent medical conditions. I have determined my condition is not life-threatening and I can wait until I arrive for evaluation and treatment. *
I agree that the facility or provider with whom I am making an appointment and/or its affiliates may contact me regarding health-related education, information, services, or advertising - our terms and conditions.