Skip to content
Home
99-2-2 Guardian Details
CMed Registration – Minor Patient Guardian
Hidden
HID Traffic Source
this variable shows where traffic came to this form from. Query string variable is checkinid
Hidden
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
Hidden
Visit ID
visit id passed to this form by booking
Hidden
HID Current Hour
hideme {current_hour}
Hidden
HID Current Minutes
Hidden
HID Decimal Time
Hidden
Today Date
captures the date of entry for use in calculations
MM slash DD slash YYYY
Hidden
Tomorrow Date
captures the date of entry for use in calculations
MM slash DD slash YYYY
Hidden
HID Pull Visit
this pulls the visit record written by booking based on the Visit ID
– Fill Out Other Fields –
Hidden
Clinic ID
Hidden
LKUP – Patient ID Verification
used to pull record from database master visit view
– Fill Out Other Fields –
Hidden
LKUP – New Patient State
= 1 is patient is new, 0 = patient is existing, no entry means patient is existing
Hidden
Patient Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)
Because the patient is a minor, they require an adult who is legally able to sign permission forms for the patient (usually the parent or guardian). The remaining information on this page is to be completed by this adult. The guarantor is the Adult, responsible for the Minor, who is signing the form.
Parent Name (Guarantor)
(Required)
First
Last
Parent Date of Birth
(Required)
We need this to verify your identity
MM slash DD slash YYYY
Hidden
Parent age
current age, no decimal needed
Your Relationship to Patient
(Required)
Parent/Step Parent
Spouse
Legal Guardian
Other
Describe Other
Hidden
Your Legal Marital Status
Single
Married
Hidden
Your Biological Sex
(Required)
Male
Female
Guarantor Address
Check here if Guardian lives at same address as Patient
Your Current 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
Parent Phone
(Required)
Parent Email
(Required)
Hidden
Section Break
St-2 P-4
Hidden
HID Traffic Source
this variable shows where traffic came to this form from. Query string variable is checkinid
Hidden
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
Hidden
Visit ID
visit id passed to this form by booking
Hidden
HID Current Hour
hideme {current_hour}
Hidden
HID Current Minutes
Hidden
HID Decimal Time
Hidden
Today Date
captures the date of entry for use in calculations
MM slash DD slash YYYY
Hidden
Tomorrow Date
captures the date of entry for use in calculations
MM slash DD slash YYYY
Hidden
HID Pull Visit
this pulls the visit record written by booking based on the Visit ID
– Fill Out Other Fields –
Hidden
Clinic ID
Hidden
LKUP – Patient ID Verification
used to pull record from database master visit view
– Fill Out Other Fields –
Hidden
LKUP – New Patient State
= 1 is patient is new, 0 = patient is existing, no entry means patient is existing
Hidden
Patient Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)
Because the patient is a minor, they require an adult who is legally able to sign permission forms for the patient (usually the parent or guardian). The remaining information on this page is to be completed by this adult. The guarantor is the Adult, responsible for the Minor, who is signing the form.
Parent Name (Guarantor)
(Required)
First
Last
Parent Date of Birth
(Required)
We need this to verify your identity
MM slash DD slash YYYY
Hidden
Parent age
current age, no decimal needed
Your Relationship to Patient
(Required)
Parent/Step Parent
Spouse
Legal Guardian
Other
Describe Other
Hidden
Your Legal Marital Status
Single
Married
Hidden
Your Biological Sex
(Required)
Male
Female
Guarantor Address
Check here if Guardian lives at same address as Patient
Your Current 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
Parent Phone
(Required)
Parent Email
(Required)
Hidden
Section Break
St-2 P-4
