Patient Forms

For a quicker wait time, please download, print, fill out, and bring any completed forms you will need with you to the clinic.

New Patient Registration Form

Authorization to Release Healthcare Information Form

Click here for a PDF containing the following forms:

  • Check-In Worksheet
  • Advanced Beneficiary Notice of Noncoverage
  • Consent for Medical Treatment of a Minor
  • Flu Shot Questionnaire
  • Sports/School Physical Patient Registration
  • TB Skin Test
  • Hepatitis B Vaccine
  • Pneumonia Vaccine


Please call us if you have any questions. Visit our Contact Us page for location information.

LaPlace (985) 359-2273     Westbank (504) 393-2273



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  • The Urgent Care

    113 Belle Terre Blvd, LaPlace
    LA 70068 . (985)359 -2273

    148 Wall Blvd, Gretna,
    LA 70056 . (504)393-2273

  • Hours

    Weekdays: 8:30am - 8:00pm

    Weekends: 8:30am - 5:00pm

    Open Holidays!

  • Connect with Us