Consumer Access Request Form

Full Name

Date of Birth

Telephone Number

Email Address

If you do not have an email address, please leave blank.

Address

City

State

Zip Code

Information being requested

Specific pieces of personal information, collected or shared with third parties and for what business/commercial purpose

Request to delete data

Terms & Agreements

We do not sell personal information that we have collected from consumers to any third parties.

By completing this form, you are making a Consumer Access request under California Consumer Privacy Act for personal information collected, held and disclosed about you that you are entitled to receive.

I understand that misrepresentation may be subject to legal action.

Consumer Access Request Form

Information being requested

Terms & Agreements

Experience easier urgent care.