||10/01/2023 12:52 PM
||Mozilla/5.0 (iPhone; CPU iPhone OS 16_6_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.6 Mobile/15E148 Safari/604.1
||Date of Birth
||Preferred Pharmacy Name
||Merrick rd amityville
||Pharmacy Street, City and State
||What is the reason for your visit?
||Do you need a COVID-19 test?
||Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell).
||Describe any current symptoms and the reason for your visit.
||Do you take any Prescription or Non-Prescription Medications?
||Norethindrone and Metformin
||List current Prescription and Non-Prescription Medications.
||Do you have Medication or Food Allergies?
||List Medication and Food Allergies. Include the reaction (rash, nausea, etc).
||None or Other
||What year was your last Flu Shot?
||Medical History (Check all that apply or None)
||Details of Other Medical History
||Surgical History (Check all that apply or None)
||Details of Other Surgical History
High Blood Pressure;
||Family History (Check all that apply to members of your immediate family or None)
||Details of Other Family History
||Are you pregnant or believe you might be pregnant?
||What was the date of your last menstrual period?
||Do you smoke cigarettes?
||Any other smoking history?
||Do you drink alcoholic beverages?
||Do you use any recreational drugs or medications not prescribed to you?
||Please specify which recreational drugs or medications you use and how often.
||Have you traveled outside of your home state in the last 30 days?
||Where did you go and when did you return?
||Do you have a runny nose?
||Describe the discharge from your nose.
||Do you have a new or worsening cough?
||Describe the frequency of cough?
||Are you coughing up phlegm?
||Do you have shortness of breath?
||Describe the shortness of breath.
||How frequent is the shortness of breath?
||Are you having chest pain?
||Have you lost your sense of taste or smell recently?
||Do you have intestinal (stomach) symptoms?
||Please check all your intestinal symptoms.
||Have you had a fever in the past 3 days?
||How high was your temperature?
||Do you have any Immune Disorders?
||Whats the cause or name of the Immune Disorder?
||Yes, I agree to all Terms.
||I, or my parent or guardian, have completed this form and consent that it is correct to the best of my knowledge. I authorize you to render necessary evaluation and treatment. I consent to Health Services and the HIPAA Privacy Notice. The practice will bill my insurance company for its services - if applicable. I understand that these services may or may not be considered a covered service by my insurance carrier. If the claim is denied by my insurance carrier as a non-covered service, the practice will bill me directly for the services and I am responsible for the payment of services in full. The practice may request a credit card number to be placed on file and to be used only if the medical claim is denied.
||Is the COVID-19 Test for any of the following? Check all that apply.
||Im not sure.
||Have you been exposed to anyone with COVID-19 in the past two weeks?
||Have you had a COVID-19 vaccine?
||Which COVID-19 vaccine did you receive?