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99-1-0 Book Time
CMed Online Booking
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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
Appointments are scheduled in 30-minute time blocks. Barring emergencies, we typically see you within that time frame. It is essential to arrive at the clinic at the START and remain throughout your scheduled block. Late arrivals may be seen on a walk-in basis, but may lose their time block spot.
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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
– Fill Out Other Fields –
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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
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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)
— select clinic —
Melissa Hwy 5
Arlington
Wichita Falls
Princeton
Haslet FM156
Haslet Avondale US287
Melissa on Hwy 121
Lantana
Telemed
Prosper
Crossroads
Heath
Mansfield
Midlothian
Celina
Training
Hurst
Frankford
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Clinic is active
Visit Date
(Required)
— Select Desired Visit Date —
12/10/2024
12/11/2024
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Clinic Message
.
– No Results –
.
The SOUTHLAKE Clinic is CLOSED FOR RENNOVATIONS
Please go to our website to see our other locations
https://communitymedcare.com/location-quickpick/
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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)
— select clinic —
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
this is the hidden database record with the definitive location
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HID Visit Date
MM slash DD slash YYYY
How can we care for you?
(Required)
Click to select a reason for visit
– Fill Out Other Fields –
If you no-show without cancelling, we may require a deposit from you for future bookings.
Preferred payment with credit/debit card. Note that we do not accept Medicaid.
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Visit Reason ID
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Visit Reason EMR 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
No
CommunityMed will see Motor Vehicle Accident injuries as a self-pay patient
and provide you the documents for the patient to file on automobile insurance for reimbursement.
Was This an injury you received while at your work?
(Required)
Yes
No
Have you previously been seen at CommunityMed for this work injury?
(Required)
Yes
No
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, Aetna, UHC, Baylor, Cigna, United Healthcare, Medicare, and Tricare).
Cash-paid, limited visit – only for youth physical
Would you like to include the Meningitis vaccine as part of your wellness visit?
Yes, I Would you like to include the Meningitis vaccine as part of the wellness visit.
Have you already used this child's annual wellness exam at another clinic this year?
(Required)
Yes
No
Unsure
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Patient's Insurance Company for Wellness
— Select Patient's Insurance Company —
Blue Cross
Cigna
United Healthcare (UHC)
Aetna
Tricare
Medicare
Other, Patient's insurance is not listed
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.
What type of workplace medical visit do you need today?
(Required)
Workplace Physical (NON-DOT)
DOT Physical
Drug Test
Breath Alcohol Test
Work Injury
Other
Is this a first time DOT Physical or a renewal?
(Required)
Renewal
First Time
PATIENT Social Security Number
(Required)
Workplace injury insurance requires a patient social security number
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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
No
Employer Info
Enter partial Company Name to Search for 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
–Select Employer–
– Fill Out Other Fields –
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)
No Bookings available – please see front desk
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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
– No Results –
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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-in 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
Current walk-in visit wait time is estimated to be less than 60 minutes
PATIENT LEGAL Name
(Required)
Name as it appears on ID or for insurance
First
Last
MONTH the PATIENT was born
(Required)
Enter the NUMERICAL month the patient was born (01 to 12)
DAY the PATIENT was born
(Required)
Enter the NUMERICAL day of the month the patient was born (01 to 31)
YEAR the PATIENT was born
(Required)
Enter the NUMERICAL year (4 digits) that the patient was born (YYYY)
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Build birthdate
CONFIRM 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)
Enter Email
Confirm Email
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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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is EPS or WC
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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. We will not sell your information. CommunityMed also uses your information for infrequent updates on other offerings. You can opt-out of receiving these communications per state and federal law. Blocking us or Opting out WILL impact our ability to intake and follow up with you.
I agree to give CommunityMed permission to text, email, call, and leave voicemails.
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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
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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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HID Arrived Flag and querystring
1=arrived, 0 = remote
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HID Arrived Flag and querystring
1=arrived, 0 = remote