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CommunityMed Family Urgent Care –
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Registration – Rapid/Paper Reg

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This is the variable set by where the customer accessed the form
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This variable is set by what parking lot the patient has checked into. Variable is Location set by querystring
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This variable is set by what parking lot the patient has checked into. Variable is Location set by querystring
Is patient in the parking lot of a CommunityMed clinic?(Required)
Has patient already started registration or reservation for this visit?(Required)
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this value is 4, set by querystring, for patient in the parking lot. Otherwise it is 0
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this value is 1 for patient in the parking lot. Otherwise it is 0
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This is the visit ID looked up from the patient entering the Z-Code.
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this will come back as null because patient does not have zcode
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1 is the visit ID is valid, 0 is the visit ID is not valid/not found
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Please Check the Z code you entered

re-enter the correct code,
or selec "No, I have not started registration" above and complete a new registration
Unable to find Visit ID Z code

Click NEXT Below and lets get you started

Click NEXT Below and lets get you started

We found your Visit ID from the Z code you entered

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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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This is the variable showing what the decimal time 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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This is the variable of how many days from today is the selected visit date.
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How many hours from now is the appointment time
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This is the clockwise hospital ID for the clinic based on the location ID of the parking lot
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This field will calculate to a 1 if there is an error to display and a 0 if there is no error
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Parking Lot Info

Patient Name(Required)
MM slash DD slash YYYY
We will use the number below to contact you IN YOUR CAR for this visit, Please add or update the number to the correct mobile phone
Is Patient New or Existing(Required)

Existing Patient

Look up existing patient by...
If patient's correct first name is not listed, please change selection above to New Patient and enter them as new
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WARNING: PATIENT NAMES DO NOT MATCH

Please change patient to NEW above if patient not found
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MM slash DD slash YYYY
MM slash DD slash YYYY
How will patient be paying for the visit today?(Required)
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the unique ID below is only for the temporary parking lot queue for patients who are starting the reg process but have not completed it yet. Iit will also be used to pull in patient details to the reg paperwork
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Additional Visit Details

Was injury the result of a car/motorcycle/truck accident?(Required)
Was injury while at work?(Required)
Type of Physical?(Required)
Is this a first time DOT Physical or a renewal?(Required)
What type of workplace medical visit needed today?(Required)
Start typing employer company name
Employer not listed
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Manage Patient

Finish Electronic Registration
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Send electronic forms for completion
Patient is signing and/or providing paper forms
Check any or all that apply
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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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Pull Data for Clockwize

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HIDDEN VID Patient Name
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MM slash DD slash YYYY
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