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
2 digit month, 2 digit day, 4 digit yearDate
Patient Name:
First, Last Name
Patient Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
The Patient being Treated is: (select one)

Other
Employee's Name:
First, Last Name
Age
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Name (if the patient is a minor)?
Relationship to Patient (if minor):
E-mail Address:
example@example.com
Employee ID Number:
Department Name:
Would you like to fill out the Sick Visit Form now or at the Clinic?
Gender / Género:
Does the patient Smoke? (age 13+)?
Patient's Primary Physician:

Primary Physician Name:
Preferred Pharmacy:
Please specify location of pharmacy (ex: Walgreens on McPherson/DelMar)
Insurance Type:
Employment Status:
Current Symptoms (select all that apply):

Other Symptoms
How Many Days with these Symptoms?
Has the patient had an ER or other clinic visit in the last 24 hours?

Yes; enter Date & Clinic/ER visited below
Medical History (select all that apply):

Other Illnesses
Has the patient had any surgeries/hospitalizations within the last year?

Yes; Enter Date & Description of prior surgeries/hospitalizations below
Allergies to any food or medications:

Yes; List any Allergies below
Current Medications being Taken:

Yes; List Medications below:
Date of Last Menstrual Cycle (if applicable):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are You Pregnant (if applicable)?

Yes, How Many Weeks?
Should be Empty:

Webb County Employee Clinic

Sick Visit Appointment