991138 |
536 |
95945 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 01:53 PM |
68.20 |
Mozilla/5.0 (Macintosh; Intel Mac OS X 10_15_7) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Safari/537.36 |
af8b0326-aed2-4840-83a6-9b58330a098a |
fre |
Location |
TYKEEMA BANKS |
Name |
05/29/1989 |
Date of Birth |
(347) 251-1453 |
Phone |
Female |
Gender |
CVS |
Preferred Pharmacy Name |
114 S Long Beach Avenue Freeport, NY |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
NASAL |
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). |
Sore throat, fever, chills, stuffy and runny nose, headache, fatigue, weakness. |
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? |
Penicillin |
List Medication and Food Allergies. Include the reaction (rash, nausea, etc). |
2021 |
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 |
None; |
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? |
February 2023 |
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? |
Yellow |
Describe the discharge from your nose. |
Yes |
Do you have a new or worsening cough? |
Very Frequent |
Describe the frequency of cough? |
Yellow |
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? |
Yes |
Have you lost your sense of taste or smell recently? |
No |
Do you have intestinal (stomach) symptoms? |
|
Please check all your intestinal symptoms. |
Yes |
Have you had a fever in the past 3 days? |
Im not sure. |
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; |
Is the COVID-19 Test for any of the following? Check all that apply. |
Its possible. |
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? |
991139 |
536 |
95948 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 01:56 PM |
68.20 |
Mozilla/5.0 (Macintosh; Intel Mac OS X 10_15_7) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/111.0.0.0 Safari/537.36 |
af8b0326-aed2-4840-83a6-9b58330a098a |
fre |
Location |
KAI BANKS |
Name |
09/13/2012 |
Date of Birth |
(347) 251-1453 |
Phone |
Female |
Gender |
CVS |
Preferred Pharmacy Name |
114 S Long Beach Avenue Freeport, NY |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
NASAL |
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). |
Runny nose, sore throat |
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). |
2021 |
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 |
None; |
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? |
n/A |
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? |
Yes |
Do you have a runny nose? |
Yellow |
Describe the discharge from your nose. |
Yes |
Do you have a new or worsening cough? |
Very Frequent |
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? |
Yes |
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. |
SCHOOL; |
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 |
No |
Have you had a COVID-19 vaccine? |
|
Which COVID-19 vaccine did you receive? |
991221 |
536 |
49690 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 03:12 PM |
166.19 |
Mozilla/5.0 (iPhone; CPU iPhone OS 15_4 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) GSA/238.1.487893381 Mobile/15E148 Safari/604.1 |
a2b6452c-9277-44ec-a4dc-473e4ba412c5 |
fre |
Location |
JAYLAH MAJANO |
Name |
12/25/2012 |
Date of Birth |
(516) 589-6171 |
Phone |
Female |
Gender |
Cvs |
Preferred Pharmacy Name |
Henry st Hempstead |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
Im Not Sure |
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). |
Headache, fever , body pain very tired |
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). |
2023 |
What year was your last Flu Shot? |
Asthma; |
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 |
No |
Are you pregnant or believe you might be pregnant? |
No period |
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. |
Yes |
Have you traveled outside of your home state in the last 30 days? |
North Carolina |
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? |
Yes |
Do you have intestinal (stomach) symptoms? |
Abdominal Pain; |
Please check all your intestinal symptoms. |
Yes |
Have you had a fever in the past 3 days? |
Im not sure. |
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. |
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 |
No |
Have you had a COVID-19 vaccine? |
|
Which COVID-19 vaccine did you receive? |
991226 |
536 |
66251 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 03:16 PM |
166.19 |
Mozilla/5.0 (iPhone; CPU iPhone OS 15_4 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) GSA/238.1.487893381 Mobile/15E148 Safari/604.1 |
a2b6452c-9277-44ec-a4dc-473e4ba412c5 |
fre |
Location |
TIFFANY MAJANO |
Name |
11/14/2009 |
Date of Birth |
(516) 589-6171 |
Phone |
Female |
Gender |
Cvs |
Preferred Pharmacy Name |
Henry st Hempstead |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
NASAL |
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). |
Stomach hurts, headaches, body aches |
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). |
2023 |
What year was your last Flu Shot? |
Asthma; |
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 |
No |
Are you pregnant or believe you might be pregnant? |
3/8/24 |
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. |
Yes |
Have you traveled outside of your home state in the last 30 days? |
North Carolina return yesterday |
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? |
Yes |
Do you have intestinal (stomach) symptoms? |
Diarrhea;
Abdominal Pain; |
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. |
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 |
No |
Have you had a COVID-19 vaccine? |
|
Which COVID-19 vaccine did you receive? |
991233 |
536 |
49694 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 03:21 PM |
166.19 |
Mozilla/5.0 (iPhone; CPU iPhone OS 15_4 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) GSA/238.1.487893381 Mobile/15E148 Safari/604.1 |
a2b6452c-9277-44ec-a4dc-473e4ba412c5 |
fre |
Location |
SARAI VARGAS |
Name |
12/28/1989 |
Date of Birth |
(516) 589-6171 |
Phone |
Female |
Gender |
Cvs |
Preferred Pharmacy Name |
Henry st Hempstead |
Pharmacy Street, City and State |
Illness |
What is the reason for your visit? |
NASAL |
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). |
Throat hurts, fever headache, stomach pain diarrhea I feel very tired my body hurts |
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). |
2023 |
What year was your last Flu Shot? |
None; |
Medical History (Check all that apply or None) |
|
Details of Other Medical History |
Other (specify); |
Surgical History (Check all that apply or None) |
Septum plastic |
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 |
No |
Are you pregnant or believe you might be pregnant? |
03/1023 |
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. |
Yes |
Have you traveled outside of your home state in the last 30 days? |
North Carolina yesterday |
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? |
Constant |
Describe the frequency of cough? |
Yellow |
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;
Heartburn; |
Please check all your intestinal symptoms. |
Yes |
Have you had a fever in the past 3 days? |
Im not sure. |
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; |
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? |
991447 |
536 |
93087 |
0 |
0 |
|
|
0 |
0 |
|
03/20/2023 |
03/20/2023 |
03/20/2023 08:11 PM |
172.58 |
Mozilla/5.0 (iPhone; CPU iPhone OS 16_3_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.3 Mobile/15E148 Safari/604.1 |
afec59ef-b27e-4a9e-92e5-346cc7d62954 |
fre |
Location |
BRITNEY RODRIGUEZ |
Name |
07/31/1996 |
Date of Birth |
(484) 632-1369 |
Phone |
Female |
Gender |
Cvs |
Preferred Pharmacy Name |
155 sunrise highway Rockville centre |
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). |
Fell down the stairs |
Describe any current symptoms and the reason for your visit. |
Yes |
Do you take any Prescription or Non-Prescription Medications? |
EVRYSDI |
List current Prescription and Non-Prescription Medications. |
Yes |
Do you have Medication or Food Allergies? |
Contrast and shell fish |
List Medication and Food Allergies. Include the reaction (rash, nausea, etc). |
2022 |
What year was your last Flu Shot? |
Other (specify); |
Medical History (Check all that apply or None) |
Spinal muscular atrophy |
Details of Other Medical History |
Tonsillectomy; |
Surgical History (Check all that apply or None) |
|
Details of Other Surgical History |
Asthma;
Cancer;
Dementia/Alzheimers;
Depression;
Diabetes;
High Blood Pressure;
High Cholesterol;
Stroke;
Thyroid Disease;
Other (specify); |
Family History (Check all that apply to members of your immediate family or None) |
Kidney disease |
Details of Other Family History |
No |
Are you pregnant or believe you might be pregnant? |
3/1/23 |
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? |
|
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. |
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? |
991707 |
536 |
66274 |
0 |
0 |
|
|
0 |
0 |
|
03/21/2023 |
03/21/2023 |
03/21/2023 01:05 PM |
172.58 |
Mozilla/5.0 (iPhone; CPU iPhone OS 16_3_1 like Mac OS X) AppleWebKit/605.1.15 (KHTML, like Gecko) Version/16.3 Mobile/15E148 Safari/604.1 |
fdd12c64-7d27-43ca-832d-853fdfde6b6b |
fre |
Location |
DEVATORI STLOUIS |
Name |
11/22/1993 |
Date of Birth |
(516) 707-7742 |
Phone |
Male |
Gender |
Cvs |
Preferred Pharmacy Name |
820 Franklin ave garden city 11530 |
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). |
I need to do in std test |
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). |
2023 |
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 |
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? |
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? |
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 |
No |
Have you had a COVID-19 vaccine? |
|
Which COVID-19 vaccine did you receive? |