Appointment Now

704 360 8893

New Patient Registration

Please fill out the form below or go back to the patient info page to download registration form.
  • Demographic/
    General Information

    1
  • Insurance
    Information

    2
  • Responsible
    Party

    3
  • Worker Compensation
    Authorisation

    4

Demographic/ General Information

Patient’s Name *
Gender
Date of Birth
SSN
Marital Status
Home Address *
City *
State *
Zip *
Email *
Main Phone Number *
Mobile Number
Work Phone number
Pharmacy Name
Pharmacy Phone
Pharmacy Address
Emergency Contact Name
Relationship
Phone Number
Ethnicity/Race
Language

We Are Accepting New Patients

If you have any questions, concerns, or comments regarding Eastway Medical Clinic & Urgent Care. You can either call us at 704 360 8893 or send us an email to info@eastwaymedicalclinic.com

We’re here for you

Eastway Medical Clinic & Urgent Care 1220 Eastway Drive Charlotte, NC 28205

Phone: 704 360 8893

Fax: 704 626 6515

hours of operation

Monday

8:30 am – 5:30 pm

Tuesday

8:30 am – 5:30 pm

Wednesday

8:30 am – 5:30 pm

Thursday

8:30 am – 5:30 pm

Friday

8:30 am – 5:30 pm

Saturday

9:00 am – 3:00 pm

Sunday

Closed

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