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CommunityMed Family Urgent Care –
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Registration – Cancel or Reschedule

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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
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Patient Name (for reference only)
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park-ID (index) for this visit in the parking lot
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park-ID (index) for this visit in the parking lot

Patient Name:

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To move a patient - just reschedule them to the other clinic

Cancel Visit

We are sorry we could not be of service for you. Please consider changing your selection above and reschedule. You can also jump onto a chat with one of our customer service team to resolve any issues
Why are you canceling? Please select all that apply(Required)
FD Why is patient visit canceled? Please select all that apply(Required)
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Reschedule

ALSO UNCANCEL - PLEASE SELECT NEW TIME AND CLINIC

Lets us know what clinic and when you would like to come in.
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MM slash DD slash YYYY
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MM slash DD slash YYYY
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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 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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Your RESCHEDULED visit is the same day as your current visit - Do you want to STAY in the parking lot OR LEAVE and COME BACK
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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