Registration – SOLV

This field is hidden when viewing the form

HIDDEN – Traffic Source

API = SOLV api entry, SOLV is patient returning to finish. This is the hidden variable set showing where the patient came from to make this booking

This field is hidden when viewing the form

Visit ID Code

Z code from visit being created by the API to pull the data for patient when they return to finish paperwork

This field is hidden when viewing the form

HIDDEN FLAG – new reg

This is the flag set 1 = new registration. Since existing reg is either error or completed, anyone going to reg forms can assume to be new registration

This field is hidden when viewing the form

HIDDEN Parking Lot Reg Temp ID

This field is hidden when viewing the form

HIDDEN Select Visit Record

This field is hidden when viewing the form

HID Parkinglot Flag and querystring

1=arrived, 0 = remote

This field is hidden when viewing the form

Current Hour

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

This field is hidden when viewing the form

Current Minute

This is the variable showing what the current minutes of the time are for when the patient is completing this form

This field is hidden when viewing the form

DecimalTime

This field is hidden when viewing the form

Today Date

MM slash DD slash YYYY

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

This field is hidden when viewing the form

Tomorrow Date

MM slash DD slash YYYY

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

This field is hidden when viewing the form

Please Select Clinic

Needs to be api populated

This field is hidden when viewing the form

NEW Clinic ID

This field is hidden when viewing the form

Visit Date

Needs to be API populated

This field is hidden when viewing the form

HID MATH TEMP Clinic ID

Needs to bed populated through api

This field is hidden when viewing the form

NEW VISIT Date

MM slash DD slash YYYY

This field is hidden when viewing the form

HIDDEN Clinic record

this is the hidden database record with the definitive location

This field is hidden when viewing the form

HID Visit Date

YYYY dash MM dash DD

Needs to be api populated

This field is hidden when viewing the form

Reason for Visit

Needs to be API populated

This field is hidden when viewing the form

NEW REASON for Visit

This field is hidden when viewing the form

HID reason for visit

Needs to be api populated

This field is hidden when viewing the form

MaxTime for Clinic and Visit Reason

This field is hidden when viewing the form

Hospital ID

This is the clockwise hospital ID for the clinic selected for the visit

This field is hidden when viewing the form

HIDDEN Days from today

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

This field is hidden when viewing the form

Early Limit visittime

This is the calculation that sets how much of todays schedule can be show to the patient

This field is hidden when viewing the form

Pick visit time block –

Needs to be populated by API

This field is hidden when viewing the form

NEW PICK visit time block

This field is hidden when viewing the form

HID timeblock for lookup

This field is hidden when viewing the form

walkinid

this is the value of the walkin visit record ID

This field is hidden when viewing the form

did not take walkin

value is 1 if patient took other than walkin, 0 if took walkin

This field is hidden when viewing the form

timeblock data pull

This field is hidden when viewing the form

HIDDEN timeblock

This field is hidden when viewing the form

Hours from now

This field is hidden when viewing the form

HID Visit Time Name

This is the name of the time block selected by the patient

This field is hidden when viewing the form

Patient Name

First Last

populate with API

This field is hidden when viewing the form

Patient Date of Birth

YYYY dash MM dash DD

Populate with API

Is the patient a NEW or EXISITING patient for CommunityMed(Required)

NEW patient – Never been to a CommunityMed before

EXISTING Patient – has been to a CommunityMed clinic before

This field is hidden when viewing the form

Patient or Parent (for minor) Email

Populate through API

This field is hidden when viewing the form

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

This field is hidden when viewing the form

FLAG – Drug Screen

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

This field is hidden when viewing the form

FLAG – MVA

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

This field is hidden when viewing the form

FLAG – Work Injury

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

This field is hidden when viewing the form

FLAG – DOT

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

This field is hidden when viewing the form

FLAG – School Physical

this flag is a 1 =the patient is school physical or 0 =the patient is not

This field is hidden when viewing the form

HID Visit time block

This variable is carried through the process as the visit time selected. This is the numerical time block (24hr time)

This field is hidden when viewing the form

Time Block ID

This field is hidden when viewing the form

HID Car Make

Pulled from parking lot record

This field is hidden when viewing the form

HID Car color

Pulled from parking lot record

This field is hidden when viewing the form

HIDDEN Arrival Time

from parking lot checkin

Visit ID

SOLV Registration

We are booking visits as a 30 minute time blocks. Unless there is an emergency at the clinic, we usually see you within that time range. IT IS CRITICAL YOU ARE AT THE CLINIC AT THE BEGINNING OF AND DURING THAT TIME BLOCK

Note that we do not accept Medicaid.

Visit Information:
Patient Name:
Patient Birthdate:
Email:
Visit time range:

Patient or Parent (for minor) Mobile Phone(Required)

The the number we should call when you are in the parking lot

Additional Visit Details

You selected injury as your reason for visit. We have a few clarifying additional questions:

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

Yes

Was This an injury you received while at your work?(Required)

Yes

What Type of Physical do you want today?(Required)

Free School Physical and Child Wellness exam for patients covered by in-network insurance. (click here to see in network carriers. Note: we are NOT in network with Medicaid plans).

$49 limited school physical for cash-pay or out-of-network

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

Renewal

First Time

What type of workplace medical visit do you need today?(Required)

Workplace Physical (NON-DOT)

Drug Test

Breath Alcohol Test

Work Injury

Other

Describe the Other kind of workplace medicine you need today?

Type the First three letter of Employer Name

This will limit the search for employers to a shorter list

Select your employer (or future employer for pre-employment services)

Employer not listed

Check here if your employer was not listed

Type Employer Company Name

This field is hidden when viewing the form

Employer_ID

Please Select “Previous” and change answer on “Reason for Visit” to Injury Visit in order to be seen for a workplace injury

This field is hidden when viewing the form

Section Break

St-SOLV1 P-1

I agree to electronic communications(Required)

In order for this medical practice to treat you, we require patients and/or guardians to give us permission to communicate with the patient and/or guardian over Mobile Phone (voice, text, and voicemail), and over email. There are inherent risks in any form of electronic communication, and CommunityMed takes a number of steps to secure your information. We will NEVER sell your information. CommunityMed will also use your information for brief and infrequent communications about important healthcare situations or offerings from the practice. We will respect this channel of contact, and you can always opt-out of receiving these communications per state and federal law. If you opt out it WILL impact our ability to communicate with you about your visit and any diagnosis, treatment, or results.

I agree to give CommunityMed permission to text, email, call, and leave voicemails.

I agree to electronic signatures on documents(Required)

I agree and understand that by selecting below the Electronic Signature Acknowledgment and Consent, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound.

I acknowledge and consent to Electronic Signature

How did you learn about CommunityMed (check all that apply)

Broadcast TV

Streaming TV or YouTube

Google Advertisment

Google Search

Community Event

Friend or Neighbor referral

Physician’s office or other medical practice referral

Drive-by seeing the location signs

From another store I frequent (e.g. Pharmacy)

Referral by kid’s school or school nurse

This field is hidden when viewing the form

Section Break

St-SOLV1 P-2