Registration – Book Time

Hidden

HIDDEN - Traffic Source

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

Hidden

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

Hidden

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

Hidden

HIDDEN Parking Lot Reg Temp ID

Hidden

HIDDEN Select Parkinglot Record

Hidden

HID Parkinglot Flag and querystring

1=arrived, 0 = remote

Hidden

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

Hidden

Current Hour

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

Hidden

Current Minute

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

Hidden

DecimalTime

Hidden

Today Date

MM slash DD slash YYYY

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

Hidden

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)

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

Hidden

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

Hidden

HIDDEN Clinic record(Required)

this is the hidden database record with the definitive location

Hidden

HID Visit Date

MM slash DD slash YYYY

Reason for Visit(Required)

Hidden

Visit Reason ID

Hidden

Visit Reason Category

Hidden

Visit Reason Timeslots

Hidden

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 School Physical and Child Wellness exam for patients covered by in-network insurance. (click here to see in network carriers. Note: we are NOT in network with Medicaid plans).

$49 limited school physical for cash-pay or out-of-network

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

Hidden

Employer_ID

Hidden

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?

Hidden

Section Break

Hidden

MaxTime for Clinic and Visit Reason

Hidden

Hospital ID

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

Hidden

HIDDEN Days from today

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

Hidden

Early Limit visittime

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

Hidden

Section Break

St-1 P-1

Pick visit time block -(Required)

Hidden

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.

Hidden

walkinid

this is the value of the walkin visit record ID

Hidden

did not take walkin

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

Hidden

timeblock data pull

Hidden

HIDDEN timeblock

Hidden

Hours from now

Hidden

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

Hidden

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)

Hidden

Section Break

Hidden

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

Hidden

FLAG - Drug Screen

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

Hidden

FLAG - MVA

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

Hidden

FLAG - Work Injury

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

Hidden

FLAG - DOT

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

Hidden

FLAG - School Physical

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

Hidden

HID Visit time block

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

Hidden

Time Block ID

Hidden

HID Car Make

Pulled from parking lot record

Hidden

HID Car color

Pulled from parking lot record

Hidden

HIDDEN Arrival Time

from parking lot checkin

Visit ID

Hidden

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

Hidden

Section Break

St-1 P-4

Hidden

HID Arrived Flag and querystring

1=arrived, 0 = remote

Hidden

HID Arrived Flag and querystring

1=arrived, 0 = remote

Hidden

check for duplicates

Hidden

Select duplicate

Hidden

VID of Duplicate

Hidden

Duplicate ID