Registration – Rapid/Paper Reg

Step 1 of 2

50%

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HIDDEN – Traffic Source

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

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Display visit reason cat

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Employee Adding

Select Location–(Required)

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Select Location

kept to keep hirotical data

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HIDDEN Clinic ID

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

THIS IS TH EOLD PAPER REG

Unless the new one is malfunctioning – please go here:
New Paper Reg

Use old paper reg anyway

New paper reg not working

I thought I was using the new one

Other

Old Paper Reg

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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

Is patient in the parking lot of a CommunityMed clinic?(Required)

Yes

Has patient already started registration or reservation for this visit?(Required)

Yes, have a VISIT ID number (starts with Z)

No Visit ID

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HIDDEN Arrived

this value is 4, set by querystring, for patient in the parking lot. Otherwise it is 0

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HIDDEN FLAG Arrived

this value is 1 for patient in the parking lot. Otherwise it is 0

Please enter your VISIT ID (Starts with a Z)(Required)

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HIDDEN visit ID code

This is the visit ID looked up from the patient entering the Z-Code.

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Lookup in View

this will come back as null because patient does not have zcode

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HIDDEN Reg Record Found flag

1 is the visit ID is valid, 0 is the visit ID is not valid/not found

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HIDDEN Patient ID from the reg record

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HIDDEN clinic ID from the reg record

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

Go ahead and create a new registration

Don’t select this option

Click NEXT Below and lets get you started

We found your Visit ID from the Z code you entered

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HIDDEN – Current Hour

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

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HIDDEN – 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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HIDDEN – DecimalTime

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

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HIDDEN – 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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HIDDEN Days from today

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

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Hours from now

How many hours from now is the appointment time

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Hospital ID

This is the clockwise hospital ID for the clinic based on the location ID of the parking lot

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HIDDEN – Wrong Location Flag

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HIDDEN – Wrong Visit DATE Flag

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HIDDEN – ERROR

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

What is Car color

What is the Make and model of car

Patient Name(Required)

First Last

Patient Date of Birth(Required)

MM slash DD slash YYYY

We will use THIS phone number to contact you for this visit(Required)

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

Patient Email(Required)

Is Patient New or Existing(Required)

New

Existing

Existing Patient

Look up existing patient by…

Cell Number

Patient name and DOB

Patient Phone Number to Lookup

Check for Existing Patient by Cell

Check for Existing Patient by Name & DOB

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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Existing Patient ID Number

Verify Patient Name

WARNING: PATIENT NAMES DO NOT MATCH

Please change patient to NEW above if patient not found

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Section Break

Reason for Visit(Required)

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Visit Reason ID

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Visit Reason Category

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Visit Reason Slots

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Min Time

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HID Visit Date

MM slash DD slash YYYY

Visit Date(Required)

MM slash DD slash YYYY

NEW FUNCTION: Clicking NEXT at the bottom of the page will let you select an AVAILABLE time for this patient. To OVERRIDE the scheduled timeslots, click the checkbox below.

OVERRIDE AVAILABLE REG TIMES

OVERRIDE AVAILABLE TIMESLOTS

Pick visit time block –

How will patient be paying for the visit today?(Required)

Patient has personal insurance

Self pay individual patient

Workers Comp Visit

EPS employment medicine employer paid

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HIDDEN timeblock

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HIDDEN Timeblock NAME

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

Parking Lot Unique ID

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HIDDEN MATH Stay in Parking Lot

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HIDDEN Create Clockwise Flag

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HIDDEN Place in line

Additional Visit Details

Was injury the result of a car/motorcycle/truck accident?(Required)

Yes

Was injury while at work?(Required)

Yes

Type of Physical?(Required)

Free School Physical and Child Wellness exam

$49 cash-pay school physical

Is this a first time DOT Physical or a renewal?(Required)

Renewal

First Time

What type of workplace medical visit needed today?(Required)

Workplace Physical (NON-DOT)

Drug Test

Breath Alcohol Test

Work Injury

Other

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

Type Employer Company Name

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Employer_ID

Manage Patient

Finish Electronic Registration

Add Patient to PV/Experity

Send patient link to finish demographics/Insurance/Guardian

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Send electronic forms for completion

HIPAA

Consent to treat

DOT Assesment

Work Injury

Motor Vehicle Accident

Patient is signing and/or providing paper forms

Check any or all that apply

Paper HIPAA form signed

Paper Consent form

Paper drug screen form and passport

Paper work comp authorization

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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

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FLAG – Drug Screen

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

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FLAG – MVA

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

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FLAG – Work Injury

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

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FLAG – DOT

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

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FLAG – School Physical

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

First Last

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HIDDEN VID Patient DOB

MM slash DD slash YYYY

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HIDDEN VID Pat Phone

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HIDDEN VID Pat Email

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HIDDEN VID Hospital ID

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HIDDEN VID New Patient

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HIDDEN VID Visit Reaosn

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Time Block ID

Visit ID