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CommunityMed Family Urgent Care –
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Registration – Book Time

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This is the hidden variable set showing where the patient came from to make this booking
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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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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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1=arrived, 0 = remote
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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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This captures the current hour of when the patient is completing this form
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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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MM slash DD slash YYYY
This is the variable that captures the date of entry for use in calculations
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MM slash DD slash YYYY
This is a variable that captures the date of entry for use in calculations
Note that we do not accept Medicaid.
The clinic is behind because we lost power. Please be patient with us.

CLINIC IS CLOSED, NO POWER

ESTIMATED open time is 1:30pm today.

Click here to register at our Melissa location on Hwy 121
Thanks for your understanding in these trying weather times.

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

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

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

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

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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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this is the hidden database record with the definitive location
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MM slash DD slash YYYY
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Additional Visit Details

Was your injury the result of a car/motorcycle/truck accident?(Required)
Was This an injury you received while at your work?(Required)
What Type of Physical do you want today?(Required)
Is this a first time DOT Physical or a renewal?(Required)
What type of workplace medical visit do you need today?(Required)
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

Employer Info

This will filter the long list of employers to minimize cell phone lookup hassle
Start typing employer company name
Employer not listed
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Please Select "Previous" and change answer on "Reason for Visit" to Injury Visit in order to be seen for a workplace injury

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This is the clockwise hospital ID for the clinic selected for the visit
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This is the variable of how many days from today is the selected visit date.
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This is the calculation that sets how much of todays schedule can be show to the patient
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St-1 P-1
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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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this is the value of the walkin visit record ID
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value is 1 if patient took other than walkin, 0 if took walkin
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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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St-1 P-2
Patient Name(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)
The the number we should call when you are in the parking lot
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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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this flag is a 1 =the patient is drug screen or 0 =the patient is not
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this flag is a 1 =the patient is motor vehicle accident or 0 =the patient is not
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this flag is a 1 =the patient is work injury or 0 =the patient is not
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this flag is a 1 =the patient is DOT or 0 =the patient is not
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this flag is a 1 =the patient is school physical or 0 =the patient is not
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This variable is carried through the process as the visit time selected. This is the numerical time block (24hr time)
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Pulled from parking lot record
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Pulled from parking lot record
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from parking lot checkin
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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 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.

How did you learn about CommunityMed (check all that apply)
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St-1 P-4
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1=arrived, 0 = remote
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1=arrived, 0 = remote
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