Sick Visit

Webb County Employee Clinic

1620 Santa Ursula Ave., Laredo, TX 78040 ~ (956) 523-5555
Sick Visit Appointment

In Person Consultations: Monday & Friday 8:00AM - 11:30AM, Wednesday 1:00PM - 4:30PM Telehealth Consultations: Monday thru Friday 8:00AM - 11:30AM & 1:00PM - 4:30PM
Select an Appointment:
Date

MonthDayYear
Date
Patient Name:*
First, Last Name
Webb County EmployeeEmployee's SpouseEmployee Dependent (Covered Under AETNA Insurance)Other
Employee's Name:
First, Last Name
Patient Date of Birth:*

MonthDayYear
Date
Age
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Name (if the patient is a minor)?
ParentGrandparentGuardianOther
E-mail Address:
example@example.com
Employee ID Number:*
Department Name:*
YesWill fill it out at the Clinic
MaleFemale
YesNo
NonePrimary Physician Name:
Preferred Pharmacy:*
Please specify location of pharmacy (ex: Walgreens on McPherson/DelMar)
Webb County AetnaPrivate InsuranceMedicaid/MedicareUninsured
Full-TimePart-Time
Abdominal PainChillsCoughCOVID-19 ExposureDiarrheaDifficulty BreathingFatigueFever or Feeling FeverishLoss of Smell/TasteMuscle or Body AchesNasal CongestionRash / Skin IrritationRunny NoseShortness of BreathSore ThroatSneezingNauseaHeadacheOther Symptoms
How Many Days with these Symptoms?*
NoYes; enter Date & Clinic/ER visited below
NoneAsthmaCancerDepression/AnxietyDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolPneumonia/BronchitisRenal (Kidney Disease)StrokeThyroid DiseaseOther Illnesses
NoneYes; Enter Date & Description of prior surgeries/hospitalizations below
NoneYes; List any Allergies below
NoneYes; List Medications below:
Date of Last Menstrual Cycle (if applicable):

MonthDayYear
Date
NoYes, How Many Weeks?
Should be Empty:

Webb County Employee Clinic

Sick Visit Appointment