990956 |
536 |
95921 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 10:13 AM |
71.11 |
Mozilla/5.0 (Macintosh; Intel Mac OS X 10_15_7) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.1 Safari/605.1.15 |
cbe7c952-2d1f-407b-bffa-06efc8ee1ad4 |
bul |
Location |
JILL GNERRE |
Name |
05/31/1979 |
Date of Birth |
(917) 626-6718 |
Phone |
Female |
Gender |
CVS |
Preferred Pharmacy Name |
501 Forest Ave., Staten Island, NY |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
No |
Do you need a COVID-19 test? |
NO |
Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell). |
sore throat, cough, chest pain |
Describe any current symptoms and the reason for your visit. |
No |
Do you take any Prescription or Non-Prescription Medications? |
|
List current Prescription and Non-Prescription Medications. |
Yes |
Do you have Medication or Food Allergies? |
levaquin |
List Medication and Food Allergies. Include the reaction (rash, nausea, etc). |
2023 |
What year was your last Flu Shot? |
None; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
Adenoids;
Breast Surgery;
C-Section;
Tonsillectomy; |
Surgical History (Check all that apply or None) |
|
Details of Other Surgical History |
Cancer;
Dementia/Alzheimers;
High Blood Pressure;
High Cholesterol; |
Family History (Check all that apply to members of your immediate family or None) |
|
Details of Other Family History |
No |
Are you pregnant or believe you might be pregnant? |
March 6 |
What was the date of your last menstrual period? |
No |
Do you smoke cigarettes? |
None; |
Any other smoking history? |
Socially |
Do you drink alcoholic beverages? |
No |
Do you use any recreational drugs or medications not prescribed to you? |
|
Please specify which recreational drugs or medications you use and how often. |
No |
Have you traveled outside of your home state in the last 30 days? |
|
Where did you go and when did you return? |
No |
Do you have a runny nose? |
|
Describe the discharge from your nose. |
Yes |
Do you have a new or worsening cough? |
Intermittent |
Describe the frequency of cough? |
No |
Are you coughing up phlegm? |
No |
Do you have shortness of breath? |
|
Describe the shortness of breath. |
|
How frequent is the shortness of breath? |
Yes |
Are you having chest pain? |
No |
Have you lost your sense of taste or smell recently? |
No |
Do you have intestinal (stomach) symptoms? |
|
Please check all your intestinal symptoms. |
No |
Have you had a fever in the past 3 days? |
|
How high was your temperature? |
No |
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. |
Yes, I have a known contact that has COVID-19. |
Have you been exposed to anyone with COVID-19 in the past two weeks? |
Chart Number |
Appointment Date |
Yes |
Have you had a COVID-19 vaccine? |
Pfizer |
Which COVID-19 vaccine did you receive? |
991002 |
536 |
95924 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 11:42 AM |
24.17 |
Mozilla/5.0 (iPhone; CPU iPhone OS 16_1_2 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.1 Mobile/15E148 Safari/604.1 |
d6e4b635-06b0-4932-8d2a-cd9c2d93bb77 |
bul |
Location |
SUNSHINE HOPKINS |
Name |
05/10/1997 |
Date of Birth |
(347) 852-7784 |
Phone |
Female |
Gender |
CVS |
Preferred Pharmacy Name |
1933 Victory Blvd |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
No |
Do you need a COVID-19 test? |
Im Not Sure |
Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell). |
I got Covid tested last week and it was negative and i haven’t been in contact with anyone who has it but I had a tiny fever and had stomach problems the last few days that have continued for weeks. |
Describe any current symptoms and the reason for your visit. |
No |
Do you take any Prescription or Non-Prescription Medications? |
|
List current Prescription and Non-Prescription Medications. |
No |
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? |
None; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
None; |
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 |
No |
Are you pregnant or believe you might be pregnant? |
01/05/2023 |
What was the date of your last menstrual period? |
No |
Do you smoke cigarettes? |
Vape/E-Cig;
Marijuana; |
Any other smoking history? |
Occasionally |
Do you drink alcoholic beverages? |
No |
Do you use any recreational drugs or medications not prescribed to you? |
|
Please specify which recreational drugs or medications you use and how often. |
No |
Have you traveled outside of your home state in the last 30 days? |
|
Where did you go and when did you return? |
No |
Do you have a runny nose? |
|
Describe the discharge from your nose. |
Yes |
Do you have a new or worsening cough? |
Occasional |
Describe the frequency of cough? |
No |
Are you coughing up phlegm? |
No |
Do you have shortness of breath? |
|
Describe the shortness of breath. |
|
How frequent is the shortness of breath? |
No |
Are you having chest pain? |
No |
Have you lost your sense of taste or smell recently? |
Yes |
Do you have intestinal (stomach) symptoms? |
Diarrhea;
Abdominal Pain; |
Please check all your intestinal symptoms. |
Yes |
Have you had a fever in the past 3 days? |
99 to 100 degrees |
How high was your temperature? |
No |
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? |
Chart Number |
Appointment Date |
Yes |
Have you had a COVID-19 vaccine? |
Pfizer |
Which COVID-19 vaccine did you receive? |
991158 |
536 |
95951 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 02:10 PM |
172.58 |
Mozilla/5.0 (iPhone; CPU iPhone OS 15_6_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/15.6.1 Mobile/15E148 Safari/604.1 |
a9fa54a8-6240-4715-9b14-140e4f33aee9 |
bul |
Location |
SABRINA ORTIZ |
Name |
07/28/2001 |
Date of Birth |
(917) 396-9471 |
Phone |
Female |
Gender |
CVS |
Preferred Pharmacy Name |
1361 Hylan Blvd, Staten Island, NY |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
No |
Do you need a COVID-19 test? |
YES |
Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell). |
-Cough, sore throat, no voice, eye pain, run down |
Describe any current symptoms and the reason for your visit. |
Yes |
Do you take any Prescription or Non-Prescription Medications? |
Unithroid, LoLoEstrin Fe |
List current Prescription and Non-Prescription Medications. |
Yes |
Do you have Medication or Food Allergies? |
Omnicef |
List Medication and Food Allergies. Include the reaction (rash, nausea, etc). |
None or Other |
What year was your last Flu Shot? |
Thyroid Disease; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
Other (specify); |
Surgical History (Check all that apply or None) |
Cardiac ablation |
Details of Other Surgical History |
Thyroid Disease; |
Family History (Check all that apply to members of your immediate family or None) |
|
Details of Other Family History |
No |
Are you pregnant or believe you might be pregnant? |
On it right now |
What was the date of your last menstrual period? |
No |
Do you smoke cigarettes? |
None; |
Any other smoking history? |
Socially |
Do you drink alcoholic beverages? |
No |
Do you use any recreational drugs or medications not prescribed to you? |
|
Please specify which recreational drugs or medications you use and how often. |
No |
Have you traveled outside of your home state in the last 30 days? |
|
Where did you go and when did you return? |
Yes |
Do you have a runny nose? |
Green |
Describe the discharge from your nose. |
Yes |
Do you have a new or worsening cough? |
Very Frequent |
Describe the frequency of cough? |
Green |
Are you coughing up phlegm? |
No |
Do you have shortness of breath? |
|
Describe the shortness of breath. |
|
How frequent is the shortness of breath? |
No |
Are you having chest pain? |
No |
Have you lost your sense of taste or smell recently? |
No |
Do you have intestinal (stomach) symptoms? |
|
Please check all your intestinal symptoms. |
No |
Have you had a fever in the past 3 days? |
|
How high was your temperature? |
Not Sure |
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? |
Chart Number |
Appointment Date |
Yes |
Have you had a COVID-19 vaccine? |
Moderna |
Which COVID-19 vaccine did you receive? |
991422 |
536 |
96058 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 07:28 PM |
67.25 |
Mozilla/5.0 (iPhone; CPU iPhone OS 16_0_3 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.0 Mobile/15E148 Safari/604.1 |
4ddc2e73-c86a-4b73-87b2-07edb6a40a7a |
bul |
Location |
KRYSTYNA BLADEK |
Name |
08/29/1991 |
Date of Birth |
(407) 508-4104 |
Phone |
Female |
Gender |
Walgreens |
Preferred Pharmacy Name |
1551 Richmond avenue sI NY |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
Im Not Sure |
Do you need a COVID-19 test? |
Im Not Sure |
Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell). |
Strep exposure from spouse , starting to feel I’ll and would like a test and antibiotics Incase |
Describe any current symptoms and the reason for your visit. |
Yes |
Do you take any Prescription or Non-Prescription Medications? |
N/a |
List current Prescription and Non-Prescription Medications. |
No |
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? |
Anxiety;
Depression; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
None; |
Surgical History (Check all that apply or None) |
|
Details of Other Surgical History |
Cancer;
Heart Disease;
High Blood Pressure;
High Cholesterol; |
Family History (Check all that apply to members of your immediate family or None) |
|
Details of Other Family History |
No |
Are you pregnant or believe you might be pregnant? |
March 3 2023 |
What was the date of your last menstrual period? |
No |
Do you smoke cigarettes? |
Marijuana; |
Any other smoking history? |
No |
Do you drink alcoholic beverages? |
Yes |
Do you use any recreational drugs or medications not prescribed to you? |
Marijuana |
Please specify which recreational drugs or medications you use and how often. |
No |
Have you traveled outside of your home state in the last 30 days? |
|
Where did you go and when did you return? |
No |
Do you have a runny nose? |
|
Describe the discharge from your nose. |
Yes |
Do you have a new or worsening cough? |
Occasional |
Describe the frequency of cough? |
Thin Clear |
Are you coughing up phlegm? |
No |
Do you have shortness of breath? |
|
Describe the shortness of breath. |
|
How frequent is the shortness of breath? |
No |
Are you having chest pain? |
No |
Have you lost your sense of taste or smell recently? |
Yes |
Do you have intestinal (stomach) symptoms? |
Abdominal Pain;
Loss of Appetite; |
Please check all your intestinal symptoms. |
No |
Have you had a fever in the past 3 days? |
|
How high was your temperature? |
No |
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. |
WORK;
SCHOOL; |
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? |
Chart Number |
Appointment Date |
Yes |
Have you had a COVID-19 vaccine? |
Moderna |
Which COVID-19 vaccine did you receive? |
991428 |
536 |
96055 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 07:34 PM |
69.19 |
Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Safari/537.36 |
05155cef-12c7-489e-ae51-6f87068498bd |
bul |
Location |
MICHELE ALTIERI |
Name |
01/10/1971 |
Date of Birth |
(347) 223-3383 |
Phone |
Female |
Gender |
CVS |
Preferred Pharmacy Name |
1654 RICHMOND AVE STATEN ISLAND NY 10314 |
Pharmacy Street, City and State |
Other |
What is the reason for your visit? |
No |
Do you need a COVID-19 test? |
NO |
Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell). |
EXTREME PAIN in left shoulder going down entire arm and UTI |
Describe any current symptoms and the reason for your visit. |
No |
Do you take any Prescription or Non-Prescription Medications? |
|
List current Prescription and Non-Prescription Medications. |
No |
Do you have Medication or Food Allergies? |
|
List Medication and Food Allergies. Include the reaction (rash, nausea, etc). |
2022 |
What year was your last Flu Shot? |
Asthma;
Neck Pain; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
Other (specify); |
Surgical History (Check all that apply or None) |
gallbladder |
Details of Other Surgical History |
Asthma;
Cancer;
Depression;
Diabetes; |
Family History (Check all that apply to members of your immediate family or None) |
|
Details of Other Family History |
No |
Are you pregnant or believe you might be pregnant? |
2 yrs |
What was the date of your last menstrual period? |
Under a pack a day |
Do you smoke cigarettes? |
None; |
Any other smoking history? |
No |
Do you drink alcoholic beverages? |
No |
Do you use any recreational drugs or medications not prescribed to you? |
|
Please specify which recreational drugs or medications you use and how often. |
No |
Have you traveled outside of your home state in the last 30 days? |
|
Where did you go and when did you return? |
No |
Do you have a runny nose? |
|
Describe the discharge from your nose. |
No |
Do you have a new or worsening cough? |
|
Describe the frequency of cough? |
|
Are you coughing up phlegm? |
No |
Do you have shortness of breath? |
|
Describe the shortness of breath. |
|
How frequent is the shortness of breath? |
No |
Are you having chest pain? |
No |
Have you lost your sense of taste or smell recently? |
No |
Do you have intestinal (stomach) symptoms? |
|
Please check all your intestinal symptoms. |
No |
Have you had a fever in the past 3 days? |
|
How high was your temperature? |
Not Sure |
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? |
Chart Number |
Appointment Date |
No |
Have you had a COVID-19 vaccine? |
|
Which COVID-19 vaccine did you receive? |
991613 |
536 |
96139 |
0 |
0 |
|
|
0 |
0 |
|
03/21/2023 |
03/21/2023 |
03/21/2023 11:00 AM |
24.19 |
Mozilla/5.0 (Linux; Android 10; SM-G960U) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Mobile Safari/537.36 |
2c02d75a-4b0e-41f6-81ad-70a3628d4418 |
bul |
Location |
DAVID OBRYANT |
Name |
10/13/1970 |
Date of Birth |
(718) 781-2991 |
Phone |
Male |
Gender |
CVS |
Preferred Pharmacy Name |
Union Avenue and forest Avenue |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
No |
Do you need a COVID-19 test? |
NO |
Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell). |
Allergic reaction |
Describe any current symptoms and the reason for your visit. |
Yes |
Do you take any Prescription or Non-Prescription Medications? |
Pacifica, Jordans |
List current Prescription and Non-Prescription Medications. |
Yes |
Do you have Medication or Food Allergies? |
Penicillin |
List Medication and Food Allergies. Include the reaction (rash, nausea, etc). |
None or Other |
What year was your last Flu Shot? |
Diabetes;
High Blood Pressure; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
None; |
Surgical History (Check all that apply or None) |
|
Details of Other Surgical History |
None; |
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? |
Under a pack a day |
Do you smoke cigarettes? |
Cigars; |
Any other smoking history? |
Socially |
Do you drink alcoholic beverages? |
No |
Do you use any recreational drugs or medications not prescribed to you? |
|
Please specify which recreational drugs or medications you use and how often. |
No |
Have you traveled outside of your home state in the last 30 days? |
|
Where did you go and when did you return? |
No |
Do you have a runny nose? |
|
Describe the discharge from your nose. |
No |
Do you have a new or worsening cough? |
|
Describe the frequency of cough? |
|
Are you coughing up phlegm? |
No |
Do you have shortness of breath? |
|
Describe the shortness of breath. |
|
How frequent is the shortness of breath? |
No |
Are you having chest pain? |
No |
Have you lost your sense of taste or smell recently? |
No |
Do you have intestinal (stomach) symptoms? |
|
Please check all your intestinal symptoms. |
No |
Have you had a fever in the past 3 days? |
|
How high was your temperature? |
Not Sure |
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? |
Chart Number |
Appointment Date |
Yes |
Have you had a COVID-19 vaccine? |
Pfizer |
Which COVID-19 vaccine did you receive? |
991645 |
536 |
96144 |
0 |
0 |
|
|
0 |
0 |
|
03/21/2023 |
03/21/2023 |
03/21/2023 12:06 PM |
108.60 |
Mozilla/5.0 (Linux; Android 13; SM-F926U1) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Mobile Safari/537.36 |
2de82861-b720-4ad4-8c93-449722940e17 |
bul |
Location |
STEPHEN BEATON |
Name |
12/12/1966 |
Date of Birth |
(718) 619-5113 |
Phone |
Male |
Gender |
Living Well Pharmacy |
Preferred Pharmacy Name |
3555 victory blvd |
Pharmacy Street, City and State |
Injury |
What is the reason for your visit? |
No |
Do you need a COVID-19 test? |
NO |
Have you had recent COVID-19 symptoms (fever, shortness of breath, cough, loss of taste or smell). |
Bit by dog difficulty moving hand |
Describe any current symptoms and the reason for your visit. |
Yes |
Do you take any Prescription or Non-Prescription Medications? |
Lunesta |
List current Prescription and Non-Prescription Medications. |
No |
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? |
None; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
Intestinal Surgery; |
Surgical History (Check all that apply or None) |
|
Details of Other Surgical History |
None; |
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? |
No |
Do you smoke cigarettes? |
None; |
Any other smoking history? |
No |
Do you drink alcoholic beverages? |
No |
Do you use any recreational drugs or medications not prescribed to you? |
|
Please specify which recreational drugs or medications you use and how often. |
No |
Have you traveled outside of your home state in the last 30 days? |
|
Where did you go and when did you return? |
No |
Do you have a runny nose? |
|
Describe the discharge from your nose. |
No |
Do you have a new or worsening cough? |
|
Describe the frequency of cough? |
|
Are you coughing up phlegm? |
No |
Do you have shortness of breath? |
|
Describe the shortness of breath. |
|
How frequent is the shortness of breath? |
No |
Are you having chest pain? |
No |
Have you lost your sense of taste or smell recently? |
No |
Do you have intestinal (stomach) symptoms? |
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Please check all your intestinal symptoms. |
No |
Have you had a fever in the past 3 days? |
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How high was your temperature? |
No |
Do you have any Immune Disorders? |
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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. |
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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? |
Chart Number |
Appointment Date |
Yes |
Have you had a COVID-19 vaccine? |
Johnson and Johnson |
Which COVID-19 vaccine did you receive? |