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Mobile Primary Care - Patient Consent and Health History Information
  • 1

    In order to complete this form, you will need the following items:

    • Your Access Code (Provided by your facility, school, or physician)
    • Primary Care Doctor and Health History Information
    • Insurance Information
    • Pharmacy Information (Including Phone Number/Address)

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  • 2
    Please enter your access code to continue. This will be provided by your facility, school, or doctor.
    Press
    Enter
  • 3
    Please Select
    • Male
    • Female
    Please Select
    • School
    • Community
    • ALF
    • SNF
    • RPM
    Press
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  • 4
    Please Enter Full Address of Patient
    Please Select
    • Please Select
    • Alabama
    • Alaska
    • Arizona
    • Arkansas
    • California
    • Colorado
    • Connecticut
    • Delaware
    • District of Columbia
    • Florida
    • Georgia
    • Hawaii
    • Idaho
    • Illinois
    • Indiana
    • Iowa
    • Kansas
    • Kentucky
    • Louisiana
    • Maine
    • Maryland
    • Massachusetts
    • Michigan
    • Minnesota
    • Mississippi
    • Missouri
    • Montana
    • Nebraska
    • Nevada
    • New Hampshire
    • New Jersey
    • New Mexico
    • New York
    • North Carolina
    • North Dakota
    • Ohio
    • Oklahoma
    • Oregon
    • Pennsylvania
    • Puerto Rico
    • Rhode Island
    • South Carolina
    • South Dakota
    • Tennessee
    • Texas
    • Utah
    • Vermont
    • Virgin Islands
    • Virginia
    • Washington
    • West Virginia
    • Wisconsin
    • Wyoming
    Please Select
    • Please Select
    • United States
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curacao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
    Press
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  • 5
    Please Select
    • Salamanca City CSD
    • Genesee Valley CSD
    • Frontier CSD
    Please Select
    • Student
    • Staff
    • Other
    Press
    Enter
  • 6
    Please Enter an Emergency Contact For This Patient
    Please Select
    • Spouse
    • Parent/Legal Guardian
    • PoA/Health Care Proxy
    • Sibling
    • Other
    Please Select
    • No
    • Yes
    Press
    Enter
  • 7
    Please Enter a Second Emergency Contact For This Patient
    Please Select
    • Spouse
    • Parent/Legal Guardian
    • PoA/Health Care Proxy
    • Sibling
    • Other
    Press
    Enter
  • 8
    Press
    Enter
  • 9
    Please Click Here For an Example Insurance Card
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    Enter
  • 10
    Press
    Enter
  • 11
    Press
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  • 12
    Press
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  • 13
    Press
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  • 14
    Press
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  • 15
    Has The Patient Ever....
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  • 16
    Please Check All That Apply
    Press
    Enter
  • 17
    Please Select
    • No
    • Yes
    Please Select
    • No
    • Yes
    Press
    Enter
  • 18
    Please Select
    • No
    • Food
    • Environmental/Seasonal
    • Insect
    • Other
    Please Select
    • No
    • Yes - Requires Glasses
    • Yes - Requires Contacts
    • Yes - Surgical Correction
    Please Select
    • No
    • Yes - Requires Hearing Aid
    • Yes = Requires Cochlear Implant
    Please Select
    • No
    • Yes - Crutches
    • Yes - Walker
    • Yes - Wheelchair
    • Yes - Other
    Please Select
    • No
    • Insulin/Blood Glucose Monitoring
    • Inhaler/Nebulizer/Peak Flow Monitoring
    • Special Diet
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  • 19
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  • 20
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  • 21
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  • 22
    Policy for Prescriptions/Narcotics/Controlled Substances
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  • 23
    HIPAA Notice of Privacy Practices
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  • 24
    Paper copies will be delivered within 7-10 business days.
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  • 25
    Press
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  • 26
    E-Signature Practices
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  • 27
    Please Sign This Form Here
    Please Select
    • Self
    • Parent/Legal Guardian
    • PoA/Health Care Proxy
    • Spouse
    • Sibling
    • Other
    Press
    Enter
  • 28
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