Forms For Your Visit

Downloadable forms for patients and employers

Urgent Care - Patient forms

Each of the patient forms and documents listed here will be copied and kept in the patient’s permanent file.

Patient Information Form (English & Spanish) — You can print and complete this patient form in advance, or complete the copy provided at check in.

Patient Authorization Form (English & Spanish) — For urgent care (a non-work-related injury or illness), you’ll need to sign a patient form that authorizes Concentra to provide services. You can print and complete this in advance or at check in.


Medical Examination Report (MER) Form, MCSA-5875

Medical Examiner's Certificate (MEC), Form MCSA-5876

Employer forms

Patient Information Form (English & Spanish) — Every patient must complete and sign this form for his/her visit. The completed form is permanently filed in the patient’s chart. This form may be printed and completed in advance, or a copy will be made available when the patient/employee arrives at a Concentra location.

Employer Authorization Form — We must have a completed and signed Employer Authorization Form for any patient coming to a Concentra Medical Center for treatment of a first-time or new injury.

Adobe Reader

You'll need Adobe Reader to view and print your patient forms. With this free download, you can access these forms prior to your visit, for added convenience.

Download Adobe Reader