Preregister Form

Atlantis Urgent Care is offering this new service to allow patients less wait time to see an emergency health professional. Please fill out the form below to be pre-registered to see a doctor. You will be given further instructions after you press the “Save my place in line” button at the bottom of the page.

Patient Information
  1. (required)
  2. (required)
  3. (required)
  4. (required)
  5. (required)
  6. (required)
  7. (required)
  8. (required)
  9. (required)
  10. (required)
  11. (required)
  12. (required)
  13. (valid email required)
Primary Insurance
Secondary Insurance
Reason for Visit
  1. (required)
  2. Is this visit related to a motor vehicle accident?
  3. Is this vist related to a work injury?
  4. Do you plan to file a lawsuit related to the condition you are here to have evaluated?
  5. If you are a female patient, are you pregnant?
Pharmacy Information
  1. (required)
  1. By clicking "Save my place in line", I hereby authorize Dr. Bjorn Dimberg to furnish all information concerning my illness and treatment to the insurance company to help secure payment for services rendered. I understand that certain insurance claims may be filed as a courtesy. However, if for any reason the claim is denied, I am responsible for payment. Please remember that insurance is considered a method of reimbursing the patient for fees to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. I understand it is my responsibility to pay any deductible amount, co-insurance or any other balance not paid by my insurance or third party payer within a period of time not to exceed 60 days. I understand that requests for completion of temporary sickness forms such as FMLA, Aflac, or travel changes will incur a $75 fee for completion.

cforms contact form by delicious:days