START

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Querystring HIDDEN – Traffic Source

checkinid: This is the variable set by where the customer accessed the form

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preload HIDDEN Parking lot Clinic ID

ARTIFICIALLY SET TO 2, ERASE WHEN DONE – This variable is set by what parking lot the patient has checked into. Variable is Location set by querystring

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preload HIDDEN Parking lot Clinic Name from ID

This variable is set by what parking lot the patient has checked into. Variable is Location set by querystring

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Clinic Details

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Is clinic active

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preload HIDDEN – DecimalTime

This is the variable showing what the decimal time the patient is completing this form

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preload HIDDEN – Today Date

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

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Clinic Parkinglot Message

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IMPORTANT MESSAGE

Clinic is currently closed –
Don’t worry – We can still book you for when we are open!

We are open Mon – Sat 8am-8pm and Sun 12pm-8pm

Please go ahead into the clinic to let the front desk know you are here and completing your paperwork.
You can still complete it on your phone, but this way we know you are here to be seen near closing.

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Section Break to show the emergency message

cant move on to next step without agreeing to the emergency message

IF PATIENT IS HAVING MEDICAL EMERGENCY THREATENING LIFE OR LIMB

Please proceed directly into the clinic with your ID and insurance card.

Medical emergencies may include, but are not limited to:

Chest pain
Symptoms of a stroke (e.g. facial drooping arm/leg weakness or paralysis, speech difficulty)
Distressing difficulty breathing
Severe trauma or bleeding
Severe abdominal pain
Drug overdose/accidental poisonings

IMPORTANT MESSAGE

Clinic is currently closed – Don’t worry – We can still book you for when we are open!

Section Break to show the emergency message

IF PATIENT IS HAVING MEDICAL EMERGENCY THREATENING LIFE OR LIMB

Clinic is currently closed –
Don’t worry – We can still book you for when we are open!