2.txmedreg.comCommunityMed Family Urgent Care –

Registration – Book Time Hidden HIDDEN – Traffic Source This is the hidden variable set showing where the patient came from to make this booking Hidden Hidden Marketing Campaign Variable set by cp querystring Hidden Reason for visit starting category Hidden Reason for visit ending category Hidden Display Cat of Visit Reason QUICK REG FOR OFFSITE TIME BOOKING We are booking visits as a 30 minute time blocks. Unless there is an emergency at the clinic, we usually see you within that time range. IT IS CRITICAL YOU ARE AT THE CLINIC AT THE BEGINNING OF AND DURING THAT TIME BLOCK Hidden HIDDEN FLAG – new reg This is the flag set 1 = new registration. Since existing reg is either error or completed, anyone going to reg forms can assume to be new registration Hidden HIDDEN Parking Lot Reg Temp ID Hidden HIDDEN Select Parkinglot Record – Fill Out Other Fields – Hidden HID Parkinglot Flag and querystring 1=arrived, 0 = remote Hidden HID Arrived Flag and querystring 1=arrived, 0 = remote We are booking visits during a 30 minute time block. Unless there is an emergency at the clinic, your visit will be within that time range. IT IS CRITICAL YOU ARE AT THE CLINIC AT THE BEGINNING OF (AND DURING) THAT TIME BLOCK Hidden Current Hour This captures the current hour of when the patient is completing this form Hidden Current Minute This is the variable showing what the current minutes of the time are for when the patient is completing this form Hidden DecimalTime Hidden Today Date MM slash DD slash YYYY This is the variable that captures the date of entry for use in calculations Hidden Tomorrow Date MM slash DD slash YYYY This is a variable that captures the date of entry for use in calculations Please Select Clinic (Required) — select clinic — Melissa Hwy 5 Arlington Wichita Falls Princeton Haslet FM156 Haslet Avondale US287 McKinney Melissa on Hwy 121 Lantana Telemed Prosper Crossroads Heath Mansfield Midlothian Celina Visit Date (Required) — Select Desired Visit Date — 05/12/2024 05/13/2024 Hidden Clinic Message – Fill Out Other Fields – Please Don’t Cancel Inside of an Hour or No Show If you book but do not show up without cancelling or cancel with less than an hour before your appointment, we may require a deposit from you for future bookings . Preferred payment with credit/debit card. Note that we do not accept Medicaid. The SOUTHLAKE Clinic is CLOSED FOR RENNOVATIONS Please go to our website to see our other locations https://communitymedcare.com/location-quickpick/ Hidden HID MATH TEMP Clinic ID This is the clinic ID for the clinic selected as the destination clinic from either parking lot querystring, other querystring, or selecting the location manually if not in parkinglot Hidden HIDDEN Clinic record (Required) — select clinic — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 this is the hidden database record with the definitive location Hidden HID Visit Date MM slash DD slash YYYY Reason for Visit (Required) — Select Reason for Visit — – Fill Out Other Fields – Hidden Visit Reason ID Hidden Visit Reason Category Hidden Visit Reason Timeslots Hidden HID reason for visit Additional Visit Details Was your injury the result of a car/motorcycle/truck accident? (Required) Yes No Was This an injury you received while at your work? (Required) Yes No What Type of Physical do you want today? (Required) Free Youth Physical and Child Wellness exam for patients covered by in-network insurance. (IN NETWORK is only for Blue Cross, Aetna, UHC, Baylor, Cigna, United Healthcare, Medicare, and Tricare). Cash-paid, limited visit – only for youth physical Have you already used this child’s annual wellness exam at another clinic this year? (Required) Yes No Unsure Patient’s Insurance Company for Wellness — Select Patient’s Insurance Company — Blue Cross Cigna United Healthcare (UHC) Aetna Tricare Medicare Other, Patient’s insurance is not listed Child Wellness If you have in-network insurance and you have already used your Child Wellness exam for the year, we will bill you after the visit for the school physical visit at the STANDARD $49 price. Is this a first time DOT Physical or a renewal? (Required) Renewal First Time What type of workplace medical visit do you need today? (Required) Workplace Physical (NON-DOT) Drug Test Breath Alcohol Test Work Injury Other Do you have an email from "First Advantage" about this visit? If your employer uses the services of First Advantage, you will have received and email from First Advantage about this visit Yes No Employer Info Enter the first 4 letters of Employer Company Name This will filter the long list of employers to minimize cell phone lookup hassle Select your employer (or future employer for pre-employment services) Start typing employer company name –Select Employer– – Fill Out Other Fields – Employer not listed Check here if your employer was not listed Hidden Employer_ID Hidden Section Break Type Employer Company Name Please Select Previous” and change answer on Reason for Visit” to Injury Visit in order to be seen for a workplace injury Describe the Other kind of workplace medicine you need today? Hidden Section Break Hidden MaxTime for Clinic and Visit Reason Hidden Hospital ID This is the clockwise hospital ID for the clinic selected for the visit Hidden HIDDEN Days from today This is the variable of how many days from today is the selected visit date. Hidden Early Limit visittime This is the calculation that sets how much of todays schedule can be show to the patient Hidden Section Break St-1 P-1 Pick visit time block – (Required) — Select Desired Visit Time — Hidden HID timeblock for lookup If there are not times, available, the clinic is at capacity Pop in and check with the front desk for any recent cancellations. Hidden walkinid this is the value of the walkin visit record ID Hidden did not take walkin value is 1 if patient took other than walkin, 0 if took walkin Hidden timeblock data pull – No Results – Hidden HIDDEN timeblock Hidden Hours from now Hidden HID Visit Time Name This is the name of the time block selected by the patient Current walk-n visit wait time is estimated to be less than 30 minutes Current walk-in visit wait time is estimated to be less than 60 minutes Current walk-in visit wait time is estimated to be less than 90 minutes Current walk-in visit wait time is estimated to be less than 2 hours Hidden Section Break St-1 P-2 Patient Name (Required) First Last Patient Date of Birth (Required) MM slash DD slash YYYY POSSIBLE BIRTHDATE ERROR We cannot see newborns except in emergency We apologize to our RETURNING patients I AM SO SORRY – we have a new registration system, and it is taking a couple of days to load our existing patients in the system. I know it is a hassle, but we need to ask you to fill out a few additional details you have already completed if you are a return patient. THIS WILL BE FIXED THIS WEEK. Is the patient a NEW or EXISITING patient for CommunityMed (Required) NEW patient – Never been to a CommunityMed before EXISTING Patient – has been to a CommunityMed clinic before Patient or Parent (for minor) Mobile Phone (Required) The the number we should call when you are in the parking lot Patient or Parent (for minor) Email (Required) Enter Email Confirm Email Hidden Section Break Hidden FLAG – New Patient this flag is a 1 =the patient is new or 0 =the patient is existing patient and paperwork is within a 1 year period Hidden FLAG – Drug Screen this flag is a 1 =the patient is drug screen or 0 =the patient is not Hidden FLAG – MVA this flag is a 1 =the patient is motor vehicle accident or 0 =the patient is not Hidden FLAG – Work Injury this flag is a 1 =the patient is work injury or 0 =the patient is not Hidden FLAG – DOT this flag is a 1 =the patient is DOT or 0 =the patient is not Hidden FLAG – School Physical this flag is a 1 =the patient is school physical or 0 =the patient is not Hidden HID Visit time block This variable is carried through the process as the visit time selected....