Monday-Friday 8am-8pm
Saturday-Sunday 9am-5pm

1300 S Bowen Rd, Suite A
Arlington, TX 76013

Rehoboth IV Infusion Patient Registration

Rehoboth Urgent Care IV Infusion Registration

Register to sign in for IV Infusion at Rehoboth Urgent Care

Patient Information

Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Preferred Visit Date(Required)

Preferred Visit Time(Required)

:

How did you hear about this event?

Medical History

Allergies

Allergies (if any)

Current Medications

Current Medications

Medical Conditions

Medical Conditions

Consent

Consent to Treat (PDF)
HIPAA Notice (PDF)
Notice of Privacy Practices (PDF)
Financial Policy (PDF)