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CommunityMed Family Urgent Care –
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Registration – Specialty Forms

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Additional Questions

Because your visit is related to a motor vehicle accident, we need to ask a few more questions about the accident to make sure we get you properly diagnosed and we can properly bill for your visit.

Additional Questions

Because your visit is related to a workplace injury, we need to ask a few more questions to make sure we get you properly diagnosed and we can properly bill for your visit.

Additional Questions

Because your visit is related to a drug screening, we need to ask a few more questions to make sure we follow proper drug test procedure and we can properly bill for your visit.

Additional Questions

Because your visit is related to a DOT Physical, we need to ask a few more questions to make sure we gather the proper information to complete your physical.

Additional Questions

Because your visit is related to a School Physical, we need to ask a few more questions to make sure we gather the proper information to complete your physical.
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Car Accident Questions

Necessary for us to properly diagnose the injury and file for reimbursement from insurance.
Do you have Personal Injury Protection (PIP) on YOUR car insurance?
Location of Patient during the accident

Approximate accident speed (MPH)
Collision with:

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Where on the car did it hit?

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Patient estimate of the force of the collision

How direct was the collision?
What was the Patients seat belt situation?

Other Characteristics of the accident (check all that apply):
I approve CommunityMed to file with insurance for reimbursement(Required)
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Car Insurance Info

We will file the visit with valid motor vehicle insurance. Please provide the details below:
Date of Motor Vehicle Injury
Insurance Adjuster's Name

PLEASE bring YOUR auto insurance card in with you

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Work Place Medicine

This is a Corporate Remedies covered employer visit
Is this occupational medicine or work injury visit for an employer already contracted with us, or is this a walk-in?
Is your employer paying for these services?
Does the patient have their eScreen form with barcode
What type of paperwork was issued to you? Please select who your “Service Request” has been issued from:

Work Injury Authorisation Details

Workplace Injury Details

Approximate Time of the injury
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Did you report the injury to your employer?
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Have you had a previous injury on these body parts?
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WE WILL SEND YOU THE UIL FORM

We will email you the UIL form as a fillable PDF for you to complete PRIOR to coming in.
Do you need additional physical paperwork completed for camp etc.?(Required)
There is an additional charge per form set of $10 (applicable to both free wellness school physical and cash pay $49 physical)
Are you requesting the optional EKG as part of your child's physical?(Required)

NOTE:

CommunityMed does not perform Pediatric ECGs. If you notate on your youth's UIL physical form (near the bottom right of the first page) that you would like a Pediatric ECG completed, CommunityMed will need to refer you and your youth to a Pediatric Cardiologist to undertake the ECG (with additional charges from the cardiologist). Eliminating the ECG request on your school physical paperwork will allow us to complete the physical today. We are happy to still refer you to a great cardiologist if the ECG is important to you and your child.
Has your child suffered a concussion within the last year?(Required)

IMPORTANT NOTE ON CONCUSSIONS:

If you answered yes (your child has suffered a concussion within the last year) you need to provide a clearance letter. CommunityMed is UNABLE to clear your child from a recent concussion.
WITH YOU TODAY - Do you have a copy of the physician clearance letter/note from this concussion(Required)
Is it likely that your child need eye glasses to pass an eye exam at 20/40(Required)

Important Vision Test Info:

If your child requires glasses or contacts to read an eye chart, you must have those to pass the physical exam. Your child will NOT pass if they cannot read at least 20/40 on the eye chart.
WITH YOU TODAY - Do you have your child's eye glasses?(Required)
Has a physician ever denied or restricted child's participation in activities for any heart problems?(Required)

IMPORTANT CARDIAC NOTE:

With the significant risk to your child given their cardiac history, we will need a copy of the clearance letter/note from the child's physician that restricted their activity due to heart problems.
WITH YOU TODAY - Do you have a copy of the clearance letter/note from the child's physician that restricted their activity due to heart problems?(Required)

YOUR CHILD IS UNLIKELY TO PASS THE SCHOOL PHYSICAL

Please rectify the requests for outside doctor notes and/or eye glasses in order to proceed with registration and get your child through their physical without issue.
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DOT Physical

DOT Physical Preliminary Questions

We need an answer to a few simple questions to get you in the queue for a more comprehensive questionnaire
Is this an existing commercial driver's license
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?
Do you have a recent history or have you been diagnosed with high blood pressure?(Required)
WITH YOU TODAY - Do you have Do you have an active prescription to control your high blood pressure?(Required)
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Do you have a recent history or have you been diagnosed with Diabetes?(Required)
WITH YOU TODAY do you have at LEAST ONE of the following: Most recent (within past 90 days) Hemoglobin A1C result OR recent blood sugar logs OR other record of Diabetes management?
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Do you use a CPAP machine?(Required)
Do you have documentation WITH YOU TODAY of proper use of the machine over the past 90 days?(Required)
Sometimes the machine has an app or web history.
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Do you have a history of a stroke, seizure disorder, brain tumor, or bleeding in the brain?(Required)
WITH YOU TODAY - do you have a release letter from your Neurologist including documentation of any medications(Required)
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Do you have a recent history or diagnosis of heart related medical issues?(Required)
WITH YOU TODAY - do you have a release letter from your cardiologist indicating your ability to safely drive a DOT vehicle AND documenting current medications(Required)
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Are you currently prescribed medications (Ambien, Adderall, Bentos) that may cause sedation, sleepiness, or have a warning about operating machinery or vehicles(Required)
WITH YOU TODAY - do you have a release letter (within the last 90 days) and medical documentation on the safety of taking these medications and driving a commercial vehicle(Required)
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Have you permanently lost use of any limb(Required)
WITH YOU TODAY - do you have a note from a medical provider describing the injury and any required work restrictions(Required)
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Are you currently taking blood thinners?(Required)
WITH YOU TODAY - do you have documentation from a medical provider indicating you INR (Internationalized-normalized ratio)(Required)
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WITH YOU TODAY - do you have a documented sleep study(Required)
Your BMI was over the 40 threshold requiring a sleep study to release you for DOT
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Do you wear corrective lenses or contact lenses or hearing aids?(Required)
Do you have those lenses/glasses or hearing aid with you today for the exam?(Required)
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Because you are missing required documentation of your medical history/conditions, we will be unable to complete a DOT exam for you today

Please return and/or reschedule when you have the necessary documentation.
Click here for a list of required DOT exam documentation
FOR CASH-PAY DOT - Acknowledging Payment for test, regardless of pass/fail(Required)
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This depression screening needs to be completed by the child, and a copy will be sent to the provider as a part of the school physical registration
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TO BE ANSWERED BY PATIENT - OVER THE LAST WEEK, HOW HAVE YOU BEEN "ON AVERAGE" OR "USUALLY" REGARDING THE FOLLOWING ITEMS:

1. Low mood, sadness, feeling blah or down, depressed, just can't be bothered.(Required)
2. Irritable, loosing your temper easily, feeling pissed off, loosing it.(Required)
3. Sleep Difficulties - different from your usual (over the years before you got sick): trouble falling asleep, lying awake in bed.(Required)
4. Feeling Decreased Interest In: hanging out with friends; being with your best friend; being with your partner / boyfriend / girlfriend; going out of the house; doing school work or work; doing hobbies or sports or recreation.(Required)
5. Feelings of worthlessness, hopelessness, letting people down, not being a good person.(Required)
6. Feeling tired, feeling fatigued, low in energy, hard to get motivated, have to push to get things done, want to rest or lie down a lot.(Required)
7. Trouble concentrating, can't keep your mind on schoolwork or work, daydreaming when you should be working, hard to focus when reading, getting "bored" with work or school.(Required)
8. Feeling that life is not very much fun, not feeling good when usually (before getting sick) would feel good, not getting as much pleasure from fun things as usual (before getting sick).(Required)
9. Feeling worried, nervous, panicky, tense, keyed up, anxious.(Required)
10. Physical feelings of worry like: headaches, butterflies, nausea, tingling, restlessness, diarrhea, shakes or tremors.(Required)
11. Thoughts, plans or actions about suicide or self-harm.(Required)
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Upload Drug Screen Authorization

Do you have an authorization form for your drug screen?

Upload Drug Screen Authorization

Join our Parking Lot WIFI

Uploading photos of your forms can be frustrating if you are on a weak cell phone signal

We have setup safe and secure Wifi in the parking lot especially for uploading your documents.

Go to your wifi settings and join the Wifi: CMED-CheckIn
with password: CommunityMed
FIRST TAKE PHOTOS of front and back of your form
THEN select below and upload those images.

We have logged your DOT registration

- Click Next to continue

We have logged your School Physical answers

- Click Next to continue

We have logged your Motor Vehicle Accident answers

- Click Next to continue

We have logged your Work Injury answers

- Click Next to continue
You are done with additional questions - Click next below to continue
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