Registration – Book Time

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HIDDEN – Traffic Source

This is the hidden variable set showing where the patient came from to make this booking

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Hidden Marketing Campaign

Variable set by cp querystring

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Reason for visit starting category

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Reason for visit ending category

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Display Cat of Visit Reason

QUICK REG FOR OFFSITE TIME BOOKING

We are booking visits as a 30 minute time blocks. Unless there is an emergency at the clinic, we usually see you within that time range. IT IS CRITICAL YOU ARE AT THE CLINIC AT THE BEGINNING OF AND DURING THAT TIME BLOCK

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HIDDEN FLAG – new reg

This is the flag set 1 = new registration. Since existing reg is either error or completed, anyone going to reg forms can assume to be new registration

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HIDDEN Parking Lot Reg Temp ID

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HIDDEN Select Parkinglot Record

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HID Parkinglot Flag and querystring

1=arrived, 0 = remote

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HID Arrived Flag and querystring

1=arrived, 0 = remote

We are booking visits during a 30 minute time block. Unless there is an emergency at the clinic, your visit will be within that time range. IT IS CRITICAL YOU ARE AT THE CLINIC AT THE BEGINNING OF (AND DURING) THAT TIME BLOCK

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Current Hour

This captures the current hour of when the patient is completing this form

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Current Minute

This is the variable showing what the current minutes of the time are for when the patient is completing this form

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DecimalTime

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Today Date

MM slash DD slash YYYY

This is the variable that captures the date of entry for use in calculations

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Tomorrow Date

MM slash DD slash YYYY

This is a variable that captures the date of entry for use in calculations

Please Select Clinic(Required)

Visit Date(Required)

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Clinic Message

Note that we do not accept Medicaid.

Preferred payment with credit/debit card

The SOUTHLAKE Clinic is CLOSED FOR RENNOVATIONS

Please go to our website to see our other locations

https://communitymedcare.com/location-quickpick/

CLINIC CLOSED FOR UTILITY POWER LOSS

WE WILL REOPEN TOMORROW

The Haslet Clinics are CLOSED today (1/30/2023) for bad weather

The Clinic is CLOSED today (1/31/2023) for bad weather

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HID MATH TEMP Clinic ID

This is the clinic ID for the clinic selected as the destination clinic from either parking lot querystring, other querystring, or selecting the location manually if not in parkinglot

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HIDDEN Clinic record(Required)

this is the hidden database record with the definitive location

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HID Visit Date

MM slash DD slash YYYY

Reason for Visit(Required)

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Visit Reason ID

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Visit Reason Category

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Visit Reason Timeslots

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HID reason for visit

Additional Visit Details

Was your injury the result of a car/motorcycle/truck accident?(Required)

Yes

Was This an injury you received while at your work?(Required)

Yes

What Type of Physical do you want today?(Required)

Free Youth Physical and Child Wellness exam for patients covered by in-network insurance. (IN NETWORK is only for Blue Cross, Cigna, United Healthcare, Medicare, and Tricare).

Cash-paid, limited visit – only for youth physical

Have you already used this child's annual wellness exam at another clinic this year?(Required)

Yes

Unsure

Patient's Insurance Company for Wellness

Child Wellness

If you have in-network insurance and you have already used your Child Wellness exam for the year, we will bill you after the visit for the school physical visit at the STANDARD $49 price.

Is this a first time DOT Physical or a renewal?(Required)

Renewal

First Time

What type of workplace medical visit do you need today?(Required)

Workplace Physical (NON-DOT)

Drug Test

Breath Alcohol Test

Work Injury

Other

Do you have an email from "First Advantage" about this visit?

If your employer uses the services of First Advantage, you will have received and email from First Advantage about this visit

Yes

Employer Info

Enter the first 4 letters of Employer Company Name

This will filter the long list of employers to minimize cell phone lookup hassle

Select your employer (or future employer for pre-employment services)

Start typing employer company name

Employer not listed

Check here if your employer was not listed

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Employer_ID

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Section Break

Type Employer Company Name

Please Select “Previous” and change answer on “Reason for Visit” to Injury Visit in order to be seen for a workplace injury

Describe the Other kind of workplace medicine you need today?

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Section Break

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MaxTime for Clinic and Visit Reason

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Hospital ID

This is the clockwise hospital ID for the clinic selected for the visit

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HIDDEN Days from today

This is the variable of how many days from today is the selected visit date.

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Early Limit visittime

This is the calculation that sets how much of todays schedule can be show to the patient

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Section Break

St-1 P-1

Pick visit time block –(Required)

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HID timeblock for lookup

If there are not times, available, the clinic is at capacity

Pop in and check with the front desk for any recent cancellations.

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walkinid

this is the value of the walkin visit record ID

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did not take walkin

value is 1 if patient took other than walkin, 0 if took walkin

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timeblock data pull

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HIDDEN timeblock

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Hours from now

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HID Visit Time Name

This is the name of the time block selected by the patient

Current walk-n visit wait time is estimated to be less than 30 minutes

Current walk-in visit wait time is estimated to be less than 60 minutes

Current walk-in visit wait time is estimated to be less than 90 minutes

Current walk-in visit wait time is estimated to be less than 2 hours

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Section Break

St-1 P-2

Patient Name(Required)

First Last

Patient Date of Birth(Required)

MM slash DD slash YYYY

POSSIBLE BIRTHDATE ERROR

We cannot see newborns except in emergency

We apologize to our RETURNING patients

I AM SO SORRY – we have a new registration system, and it is taking a couple of days to load our existing patients in the system. I know it is a hassle, but we need to ask you to fill out a few additional details you have already completed if you are a return patient. THIS WILL BE FIXED THIS WEEK.

Is the patient a NEW or EXISITING patient for CommunityMed(Required)

NEW patient – Never been to a CommunityMed before

EXISTING Patient – has been to a CommunityMed clinic before

Patient or Parent (for minor) Mobile Phone(Required)

The the number we should call when you are in the parking lot

Patient or Parent (for minor) Email(Required)

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Section Break

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FLAG – New Patient

this flag is a 1 =the patient is new or 0 =the patient is existing patient and paperwork is within a 1 year period

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FLAG – Drug Screen

this flag is a 1 =the patient is drug screen or 0 =the patient is not

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FLAG – MVA

this flag is a 1 =the patient is motor vehicle accident or 0 =the patient is not

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FLAG – Work Injury

this flag is a 1 =the patient is work injury or 0 =the patient is not

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FLAG – DOT

this flag is a 1 =the patient is DOT or 0 =the patient is not

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FLAG – School Physical

this flag is a 1 =the patient is school physical or 0 =the patient is not

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HID Visit time block

This variable is carried through the process as the visit time selected. This is the numerical time block (24hr time)

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Time Block ID

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HID Car Make

Pulled from parking lot record

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HID Car color

Pulled from parking lot record

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HIDDEN Arrival Time

from parking lot checkin

Visit ID

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Section Break

St-1 P-3

I agree to electronic communications(Required)

We require permission to communicate with the patient and/or guardian over Mobile Phone (voice, text, and voicemail), and email. There are inherent risks in any form of electronic communication, and we will not sell your information. CommunityMed also uses your information for brief and infrequent communications about important healthcare situations or offerings. We respect this channel of contact, and you can opt-out of receiving these communications per state and federal law. Blocking us or Opting out WILL impact our ability to communicate with you about your visit and any diagnosis, treatment, or results.

I agree to give CommunityMed permission to text, email, call, and leave voicemails.

I agree to electronic signatures on documents(Required)

I agree and understand that by selecting below the Electronic Signature Acknowledgment and Consent, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound.

I acknowledge and consent to Electronic Signature

How did you learn about CommunityMed (check all that apply)

Broadcast TV

Streaming TV or YouTube

Google Advertisment

Google Search

Community Event

Friend or Neighbor referral

Physician’s office or other medical practice referral

Drive-by seeing the location signs

From another store I frequent (e.g. Pharmacy)

Referral by kid’s school or school nurse

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Section Break

St-1 P-4

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HID Arrived Flag and querystring

1=arrived, 0 = remote

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HID Arrived Flag and querystring

1=arrived, 0 = remote

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check for duplicates

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Select duplicate

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VID of Duplicate

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Duplicate ID