Swift Urgent Care – Patient Registration

Patient Registration

Patient Data Consent & Registration

Please provide accurate information. Required fields must be completed before your registration can be submitted.

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Basic personal and registration information.

Branch Swift Urgent Care – Eko Atlantic City

Full Name Last Name, First Name, Middle Name

Date of Consent Set automatically

Date of Registration Set automatically

Date of Birth

Age Calculated automatically

Gender

Marital Status

Your contact details and place of residence.

Phone Number

Alternate Phone

Email Address

Residential Address

Additional demographic information.

State of Origin

LGA of Origin

Ethnic Group

Nationality

Occupational and employment details.

Occupation

Employment Status

Employer Required for employed and self-employed patients.

Person to contact when necessary.

Full Name

Relationship

Address

Phone Number

Help us understand how patients discover Swift Urgent Care.

Select an Option

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Ready to submit?

Review your information carefully before completing your registration.

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Registration Successful

Your registration has been received.

Reference Code

Please keep this reference code for your records.