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51
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1
Please select your type of Visit
*
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Urgent/ Primary Care
COVID Testing with Consultation (Insured or Self Pay)
Curbside COVID Testing (Self-pay only)
Work Related Visit
School / Sports Physical
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2
Do you have a Curbside appointment?
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YES
NO
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3
We're sorry, Curbside testing requires an appointment.
Please go here
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4
Do you have an appointment?
*
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YES
NO
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5
Time
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Minutes
AM
PM
AM
AM
PM
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6
Employer Services
*
This field is required.
Please select all that apply.
Work-Related Injury (First Visit)
Work-Related Injury (Follow-up)
Pre-Employment Physical
DOT Physical
Drug Screen
DOT Drug Screen
Breath Alcohol Test
TB Test
Other
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7
Who sent you today?
Please Select
Employer
Agency
Risk Manager
Supervisor
Self
Please Select
Please Select
Employer
Agency
Risk Manager
Supervisor
Self
Employer/Supervisor/Agency Name
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8
Have you been here before?
YES
NO
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9
Patient Name
First Name
Middle Name
Last Name
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10
Date of Birth
-
Month
Day
Year
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11
If Patient is a Minor
Parent/ Guardian
Relationship
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12
Phone Number
Area Code
Phone Number
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13
Email
example@example.com
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14
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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15
Patient Information
Social Security Number
Occupation
Employer
Employer Phone
Please Select
Single
Married
Divorced
Widowed
Child
Please Select
Please Select
Single
Married
Divorced
Widowed
Child
Marital Status
Spouse
Emergency Contact
Phone
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16
What is the reason for your visit?
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Ok
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17
Please list any relevant medical history.
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18
Please list any current medications.
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Ok
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19
Do you have a primary care physician?
Physician Name
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20
When did the injury occur?
*
This field is required.
-
Date
Month
Day
Year
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21
Describe how the injury occurred:
*
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Please be very descriptive in your details.
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22
Where were you when the injury occurred?
*
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23
When did you first report the injury to your supervisor?
*
This field is required.
-
Date
Year
Month
Day
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24
What parts of your body were injured?
*
This field is required.
(i.e. Low Back, Right Hand, Left Foot)
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Ok
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25
Have you been treated elsewhere for this injury prior to your visit today?
*
This field is required.
YES
NO
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26
Where have you been treated for this injury?
Place of Treatment 1
Date(s) Treated
Place of Treatment 2
Date(s) Treated
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27
What is your official job title (if known)?
*
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28
What do you do at work?
*
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29
How long have you been employed with this employer?
*
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30
Have you had any other on the job injuries? If so, please list the injury and the date.
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31
Have you ever had any past injury or treatment to the body areas involved in the current work injury? If so, please describe.
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32
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33
Any additional comments?
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34
Will you be using insurance for today's visit?
*
This field is required.
YES
NO
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35
Insurance Information
Primary Insurance
Policy Number
Group Number
Please Select
Policy Holder
Spouse
Dependent
Please Select
Please Select
Policy Holder
Spouse
Dependent
Patient is:
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36
Policy Holder Information
Name
Date of Birth
Social Security Number
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37
Please scan front of insurance card.
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38
Please scan back of insurance card.
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39
Please scan your ID.
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40
How will you be paying today's visit/balance?
Cash
Credit/Debit Card
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41
Have you been exposed to anyone who has tested positive for COVID-19?
YES
NO
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42
Are you experiencing any of the following?
High fever
Cough
Difficulty in breathing
Persistent pain or pressure in the chest
Body aches
Nasal congestion
Runny nose
Sore throat
Diarrhea
Headache
Abdominal Pain
Chills
Nausea or Vomiting
Other
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43
Please check all that apply
Chronic Lung Disease (Asthma/Emphysema/COPD)
Diabetes Mellitus
Cardiovascular Disease
Chronic Renal Disease
Chronic Liver Disease
Immunocompromised Condition
Neurologic / Neurodevelopmental / Intellectual Disability
If Female, Currently Pregnant
Current Smoker
Former Smoker
Other
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44
How did you hear about us?
Please select all that apply.
Google Search
Friend
Doctor
Work
Drove by
Radio
TV
Facebook
Instagram
Twitter
Internet Ad
Other
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45
Patient Consent for Treatment
*
This field is required.
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46
Protected Health Information
*
This field is required.
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47
Financial Responsibility
*
This field is required.
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48
COVID Results Time-Frame
*
This field is required.
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49
Employer-requested Procedure Disclosure
*
This field is required.
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50
Work Injury Disclosure
*
This field is required.
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51
Notice of Privacy Practices
*
This field is required.
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52
Please let us know what vehicle to look for
(As a COVID-19 safety measure, you may be asked to wait in your vehicle rather than our waiting room.)
Make
Model
Color
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53
Do you have a preferred pharmacy?
Preferred Pharmacy Name and Location
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54
Patient Signature or Guardian (if minor)
*
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Clear
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