COVID URI Office Visit

VITAL TOTAL HEALTH Medical Group, Inc.

Telemedicine: www.vitaloncall.com

Walnut Creek, San Francisco, Castro Valley, Pittsburg, Sacramento, S Pasadena, W Hollywood, San Diego

Mailing Address: 710 S Broadway, Suite 212, Walnut Creek, California 94596

Email: info@vitaltotalhealth.com

State Telephone & Fax (925) 388-9800
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Insurance*
Insurance ID number
Take Photo of Driver's License or ID
Take Photo of Front of Insurance Card
Take Photo of Back of Insurance Card
Complaints or Symptoms*

FeverChillsCoughShort of BreathSore throatNasal StuffinessLoss of SmellLoss of TasteFatigueMuscle AchesNauseaVomitingDiarrheaExposed to CovidExhaustion
PAST MEDICAL HISTORY

High Blood PressureSugar DiabetesHeart DiseaseAsthmaCOPDLiver DiseaseKidney DiseaseCancerOrgan TransplantCovid Positive in Past
I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled, private insurance and other health plans, to VITAL TOTAL HEALTH MEDICAL GROUP, INC. The assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize Vital Total Health Medical Group, Inc., to use, to disclose, and to release any of my personal and healthcare information to secure payment. I authorize Vital Total Health Medical Group, Inc. to release my medical information to any physicians and healthcare providers as well as adjustors, case managers, vocational counselors, and pharmacists. I further authorize any physicians and healthcare providers to release my medical, laboratory, x-ray and diagnostic, pharmaceutical, and psychiatric records to Vital Total Health Medical Group, Inc.
Print Name*
Signature*

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Date*

MonthDayYear
Date
PHYSICAL EXAM:
Temp: Normal or Fever
Pulse Rate
O2 Sat
Height
Weight

Breathing:*

	APPEARANCE
No Acute Distress
Difficulty Breathing
In Physical Distress
Breathing Normal Rate
Short of Breath

DIAGNOSES*

	Diagnoses
J06.9 Upper Respiratory Infection
R53.83 Fatigue
Z20.828 Exposure to Covid
U07.1 Covid 19
B94.8 Chronic Covid

Place of Service:*

	Place of Service
04 Homeless Shelter
12 Home
13 Assisted Living
14 Group Home

Procedure*

	Not Satisfied
New Patient 99202
New Patient 99203 (Medications ordered)
Follow Up 99211
Follow Up 99212 (MD saw patient)
Follow Up 99213 (Physician ordered Medications

PLAN:*

	Not Satisfied
Covid 19 RPR Test Order
Medications Rec: Prednisone
Medications Rec: Z-pak
Patient refused Medications
Follow Up if persists or worsen

Dr Michael Zizmor, MD

Dr Benjamin Greer, MD

Sukanya Holmes, MD

Nataliya Stogniy, PA-C

Rose Fisher, PA-C

Andrew Valadez, PA-C

Link for Video: vthmg.doxy.me/frontofficec
Medical Assistant Name print*
MA signature*

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