After Hours Hospital/Urgent Care Notification

If you need to go to the hospital or an urgent care facility after hours please utilize this form to notify the team at Holland Medi Center of your visit so that we can follow up with your company/organization on the next business day.

Company/Organization(Required)

Employee Name(Required)

First Last

Employee Date of Birth(Required)

Urgent Care / Hospital(Required)

Name of Person Submitting this Form(Required)

First Last

Phone

This field is for validation purposes and should be left unchanged.

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