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99-2-0N Registration – Demographics New Patients
24-50555512129786-24
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HID Traffic Source
this variable shows where traffic came to this form from. Query string variable is checkinid
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DO WE NEED? HID Arrived
this variable is set to 4 when patient has arrived in the parking lot. the querystring variable is arvd. Default value is 0
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Visit ID
visit id passed to this form by booking
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HID Decimal Time
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Today Date
captures the date of entry for use in calculations
MM slash DD slash YYYY
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Tomorrow Date
captures the date of entry for use in calculations
MM slash DD slash YYYY
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HID Pull Visit
this pulls the visit record written by booking based on the Visit ID
– Fill Out Other Fields –
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Patient ID
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Patient data pull
– Fill Out Other Fields –
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LKUP – New Patient State
= 1 is patient is new, 0 = patient is existing, no entry means patient is existing
Patient Details
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Patient Name
(Required)
First
Last
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Patient Date of Birth
(Required)
MM slash DD slash YYYY
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New or existing patient
New Patient
Existing Patient
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Patient (or parent for minors) Mobile Phone
(Required)
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Patient (or parent for minors) Email
(Required)
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Patient Age
PATIENT Address Info
Patient Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Patient Demographics
Patient Biological Sex
(Required)
Male
Female
Patient Marital Status
(Required)
Married
Single
N/A
Parent or Guardian Social Security Number
(Required)
Information is used for billing – will be kept confidential
Patient Social Security Number
(Required)
Information is used for billing – will be kept confidential
Name of Preferred Pharmacy
What is the name or partial name of your preferred pharmacy (For example Walgreens)
In what city is that pharmacy?
What is the name of the city where the Pharmacy is located?
Select Preferred Pharmacy from Filtered Options
–Select Pharmacy from list —
– Fill Out Other Fields –
Family Physician
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Preferred Pharmacy
Map Selection
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Section Break
St-2 P-3
