Sick Visit

Webb County Employee Clinic

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

MonthDayYear
Date
Patient Name:*
First, Last Name
The Patient being Treated is: (select one)*

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.
Does the patient Smoke? (age 13+)?*

YesNo
Parent/Guardian Name (if the patient is a minor)?
Relationship to Patient (if minor):

ParentGrandparentGuardianOther
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?*

YesWill fill it out at the Clinic
Gender / Género:*

MaleFemale
Patient's Primary Physician:*

NonePrimary Physician Name:
Preferred Pharmacy:*
Please specify location of pharmacy (ex: Walgreens on McPherson/DelMar)
Insurance Type:*

Webb County AetnaPrivate InsuranceMedicaid/MedicareUninsured
Employment Status:*

Full-TimePart-Time
Current Symptoms (select all that apply):

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?*
Has the patient had an ER or other clinic visit in the last 24 hours?*

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

NoneAsthmaCancerDepression/AnxietyDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolPneumonia/BronchitisRenal (Kidney Disease)StrokeThyroid DiseaseOther Illnesses
Has the patient had any surgeries/hospitalizations within the last year?*

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

NoneYes; List any Allergies below
Current Medications being Taken:*

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

MonthDayYear
Date
Are You Pregnant (if applicable)?

NoYes, How Many Weeks?
Should be Empty:

Webb County Employee Clinic

Sick Visit Appointment