iMed Urgent Care
1
Patient Information
2
Insurance & ID
3
HIPAA Consent
4
Medical Consent
5
Communication
6
Telehealth
7
Privacy Practices
8
Financial Responsibility
Patient Intake Information
Patient First Name
*
Patient Middle Name
Patient Last Name
*
Date of Birth
*
Social Security Number
Phone Number
*
Email Address
*
Residential Address
Street Address / Apartment
*
City
*
State
*
Zip Code
*
Emergency Contact Details
Emergency Contact Name
*
Relation to Patient
Emergency Contact Phone
*
Referral & Intake Screening
How did you hear about us?
What is your friend's name?
Reason for Visit
Are you currently in pain?
Preferred Pharmacy Name
Pharmacy Location
Pharmacy Phone Number
Current Medications, Vitamins, or Supplements
Please indicate if you have had any of the following:
Chest pain / Heart condition
Renal / Kidney Disease
Stroke
High Blood Pressure
Diabetes
Bleeding Disorder
Cancer
Hepatitis / Liver Disease
Seizures / Epilepsy
Glaucoma
Thyroid condition
Prostate condition
Use of Blood Thinners
Use of Steroids
Recreational Drug Use
Smoker / Tobacco Use
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iMed Urgent Care — Patient Registration System