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CommunityMed Family Urgent Care –
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Registration – SOLV

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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
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Z code from visit being created by the API to pull the data for patient when they return to finish paperwork
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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
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1=arrived, 0 = remote
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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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Needs to be api populated
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Needs to be API populated
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Needs to bed populated through api
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MM slash DD slash YYYY
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this is the hidden database record with the definitive location
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YYYY dash MM dash DD
Needs to be api populated
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Needs to be API populated
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Needs to be api populated
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This is the clockwise hospital ID for the clinic selected for the visit
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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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Needs to be populated by API
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this is the value of the walkin visit record ID
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value is 1 if patient took other than walkin, 0 if took walkin
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This is the name of the time block selected by the patient
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Patient Name
populate with API
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YYYY dash MM dash DD
Populate with API
Is the patient a NEW or EXISITING patient for CommunityMed(Required)
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Populate through API
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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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This variable is carried through the process as the visit time selected. This is the numerical time block (24hr time)
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Pulled from parking lot record
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Pulled from parking lot record
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from parking lot checkin

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:
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)
Was This an injury you received while at your work?(Required)
What Type of Physical do you want today?(Required)
Is this a first time DOT Physical or a renewal?(Required)
What type of workplace medical visit do you need today?(Required)
This will limit the search for employers to a shorter list
Employer not listed
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Please Select "Previous" and change answer on "Reason for Visit" to Injury Visit in order to be seen for a workplace injury

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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 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.

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