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)
2
Access Code* This field is required.Please enter your access code to continue. This will be provided by your facility, school, or doctor.
Access Code
3
Basic Patient Information* This field is required.
Patient First Name
Patient Last Name
Primary Telephone Number
Email Address For Electronic Contact
Please Select
Male
Female
Gender
Patient Date of Birth
Please Select
School
Community
ALF
SNF
RPM
Patient Source
4
Patient Address* This field is required.Please Enter Full Address of Patient
Street Address
Street Address Line 2
City
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
State
Zip Code
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
Country
5
School Information
Please Select
Salamanca City CSD
Genesee Valley CSD
Frontier CSD
School
Please Select
Student
Staff
Other
Patient Role
Grade Level (eg. Pre-K or Grade 6)
6
Emergency Contact* This field is required.Please Enter an Emergency Contact For This Patient
Emergency Contact First Name
Emergency Contact Last Name
Please Select
Spouse
Parent/Legal Guardian
PoA/Health Care Proxy
Sibling
Other
Emergency Contact Relationship To Patient
Emergency Contact Telephone Number
Please Select
No
Yes
Do You Have Any Additional Emergency Contact Information?
7
Additional Emergency Contact* This field is required.Please Enter a Second Emergency Contact For This Patient
Emergency Contact First Name
Emergency Contact Last Name
Please Select
Spouse
Parent/Legal Guardian
PoA/Health Care Proxy
Sibling
Other
Emergency Contact Relationship To Patient
Emergency Contact Telephone Number
8
Does The Patient Have A Primary Health Insurance* This field is required.
YESNO
9
Primary Insurance Information* This field is required.Please Click Here For an Example Insurance Card
Primary Insurance Carrier Name
Primary Insurance Subscriber Name
Primary Insurance ID Number
Primary Insurance Policy/Group Number
10
Does The Patient Have A Secondary Health Insurance* This field is required.
YESNO
11
Secondary Insurance Information* This field is required.
Secondary Insurance Carrier Name
Secondary Insurance Subscriber Name
Secondary Insurance ID Number
Secondary Insurance Policy/Group Number
12
Primary Doctor Information
Primary Care Doctor Name
Office Address
Doctor Phone Number
Doctor Fax Number
13
Pharmacy Information
Pharmacy Name
Pharmacy Address/Location
Pharmacy Phone Number
Pharmacy Fax Number
14
Additional Information
Preferred Hospital?
Additional Hospital Information (Number, Location, Etc.)
Preferred Dentist?
Additional Dentist Information (Number, Location, Etc.)
15
Medical History* This field is required.Has The Patient Ever....
Had an Ongoing Medical Condition?
Seen a Medical Specialist?
Been Hospitalized?
Had an Operation?
Fainted?
Had an Injury Requiring an Emergency Room Visit?
Missed 5 Days of School/Work in a Row Due To Illness/Injury?
Had a Bone/Muscle Injury?
Had a Concussion or Serious Head Injury?
Had a Convulsion/Seizure?
Been Diagnosed with a Bleeding Disorder?
None Of The Above
16
Medical Conditions* This field is required.Please Check All That Apply
ADHD
Asthma/Trouble Breathing
Autism/Asperger’s
Dental Injuries
Diabetes
Ear Infections
GI Conditions (Ulcer, Reflux, IBS)
Headaches/Migraines
Heart Conditions
High Blood Pressure
Mental Health Condition (Depression, Eating Disorder, Anxiety, OCD, ODD, etc)
Scoliosis
Single Organ (eg. Kidney)
Skin Condition
Speech Condition
Urinary Condition
None Of The Above
17
Have Any Family Members Under the Age of 50 Ever* This field is required.
Please Select
No
Yes
Had A Heart Attack?
Please Select
No
Yes
Had Other Serious Health Problems?
18
Does The Patient...
Please Select
No
Food
Environmental/Seasonal
Insect
Other
Have Allergies? (Non-Drug Allergies)
Please List Allergies
Please Select
No
Yes - Requires Glasses
Yes - Requires Contacts
Yes - Surgical Correction
Had a Vision Problem or Condition?
Please Select
No
Yes - Requires Hearing Aid
Yes = Requires Cochlear Implant
Had a Hearing Problem or Condition?
Please Select
No
Yes - Crutches
Yes - Walker
Yes - Wheelchair
Yes - Other
Require Any Assistive Equipment?
Please Select
No
Insulin/Blood Glucose Monitoring
Inhaler/Nebulizer/Peak Flow Monitoring
Special Diet
Require Any Treatments/Monitoring?
19
Explanation of Medical History
20
Additional Information
Huge
Large
Normal
Small
Ok
Ok
21
Patient Consent Checklist* This field is required.
22
Medicine Agreement* This field is required.Policy for Prescriptions/Narcotics/Controlled Substances
23
HIPAA Agreement* This field is required.HIPAA Notice of Privacy Practices
24
How Would You Like Your Copy Of This Form?* This field is required.Paper copies will be delivered within 7-10 business days.
Email DeliveryPaper Copy
25
Please Confirm Your Email Address* This field is required.
Please Confirm The Email Address For Electronic Delivery
26
E-Signature Agreement* This field is required.E-Signature Practices
27
E-Signature* This field is required.Please Sign This Form Here
Type E-Signature Here
Please Select
Self
Parent/Legal Guardian
PoA/Health Care Proxy
Spouse
Sibling
Other
Relationship To Patient
28
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In order to complete this form, you will need the following items: