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Registration – Cancel or Reschedule
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Step
1
of
2
50%
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Traffic Source
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Visit ID
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Employee cancel resched
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check for id
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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
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Patient Name (for reference only)
First
Last
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Patient DOB
MM slash DD slash YYYY
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ParkingLot ID
park-ID (index) for this visit in the parking lot
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Clinic ID
park-ID (index) for this visit in the parking lot
Patient Name:
Select the action (Cancel or rebook) that you want:
(Required)
— Select Cancel or Rebook —
Cancel my Visit
Reschedule my visit
FD Select the action (Cancel, Uncancel or rebook) that you want:
(Required)
— Select Cancel or Rebook —
Cancel my Visit
Reschedule my visit
UNCANCEL a canceled visit
LWOBS
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Selection for Action
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)
The wait is too long
The visit is too expensive
I am going to my Primary Care/Pediatrician instead
I got in somewhere else faster
CommunityMed does not offer the type of care I need
Other
FD Why is patient visit canceled? Please select all that apply
(Required)
Unknown – NO SHOW
Duplicate
The wait is too long
The visit is too expensive
Patient going to my Primary Care/Pediatrician instead
Patient got in somewhere else faster
CommunityMed does not offer the type of care patient needs
Visit entered in error
Other
Description of Other from above
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Reason for cancel
Left Without Being Seen
Was Patient Taken to the back before they LWOBS
(Required)
Yes
No
Did patient pay anything before they LWOBS
(Required)
Yes
No
FD Why is patient LWOBS? Please select all that apply
(Required)
Unknown – walked out
The wait is too long
The visit is too expensive
Patient going to my Primary Care/Pediatrician instead
Patient got in somewhere else faster
CommunityMed does not offer the type of care patient needs
CommunityMed does not take their insurance
Other
Provide details on OTHER
(Required)
Provide additional details
Reschedule
ALSO UNCANCEL – PLEASE SELECT NEW TIME AND CLINIC
Lets us know what clinic and when you would like to come in.
VIP – Inside the clinic Transfer?
Patient is being transferred from INSIDE the clinic to another clinic and will need VIP pass
Please Select Clinic
(Required)
— select clinic —
Melissa Hwy 5
Arlington
Wichita Falls
Princeton
Haslet FM156
Haslet Avondale US287
Southlake
McKinney
Melissa on Hwy 121
Lantana
Telemed
Prosper
Crossroads
Heath
Mansfield
Midlothian
Celina
Training
Hurst
Frankford
Visit Date
(Required)
— Select Desired Visit Date —
12/10/2024
12/11/2024
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transfer vip url
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Visit date existing visitDate
MM slash DD slash YYYY
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HID Visit Date
MM slash DD slash YYYY
Reason for Visit
(Required)
— Select Reason for Visit —
– Fill Out Other Fields –
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Visit Reason Timeslots
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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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HID reason for visit
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MaxTime for Clinic and Visit Reason
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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
Reschedule
Please pick a time block from available spots below
– Fill Out Other Fields –
Please pick a time block from available spots below – INTERNAL
– Fill Out Other Fields –
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Time Block ID
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Timeblock
– Fill Out Other Fields –
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
Stay
Lave and come back BEFORE my rescheduled visit time
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Visit TImeblock Name
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HID move to Hospital id
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Section Break
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HID Hospital 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
