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If you are experiencing Chest Pain please proceed to the nearest emergency room. If you have Shortness of Breath please call 911. Inform staff if you believe it is COVID-19 related.
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Language |
English Spanish |
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Patient First Name |
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Patient Last Name |
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Patient Date of Birth |
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Contact Person If other than patient. |
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Return Phone Number |
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Best Time To Call Callbacks available from 8am to 4:30 pm. |
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Doctor |
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Requested Date |
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Reason for Visit |
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Please Provide Current Insurance Information if Available. |
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Insurance Name |
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Subscriber ID |
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Group Number |
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Are you experiencing any respiratory symptoms? |
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Select |
YES NO |
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If YES, please select: |
Cough Fever Shortness of Breath Congestion Sore throat Runny nose Sneezing
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Have you been exposed to the flu or COVID-19? |
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Select |
YES NO |
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If YES: Who, When, and Where? |
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Have you or anyone you know traveled outside of the United States recently? |
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Select |
YES NO |
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If YES: Who, When, and Where? |
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You will be contacted to schedule your appointment as soon as possible. |
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