Check In Worksheet .pdf

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Original filename: Check In Worksheet.pdf
Title: Microsoft Word - Check In Worksheet.docx

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!
!
!

CHECK IN WORKSHEET
Name: _________________________________________, ______________________________________________
Last
First
Date of Birth: ______/______/________

Phone Number: _________________________________

Address: _______________________________________________________ Apt/Suite: ______________________
City: ________________________________ State: _____________________ Zip Code: ______________________
!
What%is%the%reason%for%your%visit?%________________________________________________________________!
!!!!!!!

!

!

!

!

!

(Examples:!Cough,!Ear!Infection,!Fever,!Flu,!Rash,!Sinus!Infection,!Urinary,!etc.)!

!
Are you here for a school or work physical?

Yes

No

Are you here due to injuries from a car accident?

Yes

No

Are you here due to injuries related to work?

Yes

No

Would you like a flu vaccine today?

Yes

No

Do you need a doctor’s note for school or work?

Yes

No

Preferred Pharmacy: _________________________ Cross Streets/Address: _______________________
Primary Insurance: ___________________________ Secondary Insurance: _______________________
How would you like us to educate you on your diagnosis? (Circle all that apply)
Paper Handouts

Visual Communication

Verbal Communication

HIPAA Patient Consent
By signing below, I have read and fully understand the Patient Consent for Use and Disclosure of Protected Health
Information, revised July 2016. I consent and agree to all of its terms and conditions. I understand copies of The Urgent
Care’s full Notice of Privacy Practices are available for me at my request.
Patient Responsibility
By signing below, I have read and fully understand The Urgent Care’s Patient Responsibility, revised July 2016. I accept and
agree to all of its terms and conditions. Specifically, I understand that I am responsible for any medical treatment and
medical equipment not covered by my insurance plan or applied towards my deductible. Please refer to Patient
Responsibility notice on clipboard.
Consent for Treatment
By signing below, I understand that I have a choice to be seen at The Urgent Care versus the hospital Emergency Department,
my primary care, or a specialist. I authorize The Urgent Care to provide medical treatment and services to me. I understand I
am authorizing The Urgent Care to treat me while I seek care from The Urgent Care or until I withdraw my authorization in
writing.
Signature: ___________________________________________________ Date: ________/________/__________
If you do not want to receive a call back after your visit, please check here.
148!Wall!Blvd.!Gretna,!LA!70056!|!Phone:!(504)!393A2273!!!113!Belle!Terre!Blvd.!LaPlace,!LA!70068!|!Phone:!(985)!359A2273!!


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