Charter Clinic Immediate Care Urgent Care in NW OKC SW Corner of Britton & Broadway Ext. next to McDonalds 200 W. Britton Rd. Oklahoma City OK 73114 (405) 755-8000 You can reserve your spot now for shorter waiting time. Just let us know what time you are planning on coming in. Please click here “ONLINE PATIENT FORMS” to fill Online Patient Form. New Patient I am a: New Patient Return Patient Source of Payment Self Pay BCBS SoonerCare Aetna OtherOther Patient Information First Name * Last Name * Date * Time * 121234567891011 : 000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 AMPM Phone Date of Birth * Change in Address, Phone, or Insurance? * Yes No Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Reason for Visit * Pharmacy Info Do you have a Prefered Pharmacy? No Yes Pharmacy Name Pharmacy Address Pharmacy Phone How did you hear about us? Drive By Friend Facebook Print Ad Referral Twitter OtherOther e-Signature This digital signature(e-signature) will serve as your signed signature. Submit
