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11:00am
11:30am
First Name
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Last Name
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Date of Birth
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TO SCHEDULE AN APPOINTMENT WITH DR.M PLEASE CALL THE CLINIC. ALL OTHER APPOINTMENTS WILL BE CANCELED. NO ON-LINE APPOINTMENTS FOR SICK VISIT OR COVID RELATED SYMPTOMS (must be televisit M-F or walk in M - SUN). NO ON-LINE APPOINTMENT FOR TESTING/DRUG SCREENS/DOT PHYSICALS OR WORK COMP INJURIES AS THESE ARE SEEN WITHIN A DIFFERENT DEPT. Please select your reason for visit:
Abdominal Pain
allergic reaction
Annual Physical
Biote Appt
Chest Congestion
Chest pain (heart)
Cough
COVID-potential/exposure/testing
diarrhea
Flu Shot
Headache
Injury
Medication Refill
other/muliple symptoms
Physical/Drug screen
RESEARCH
Scheduled Appt-Online
Shortness of Breath
Sinus Infection
UTI
Vomiting
You understand that you must do a Televisit appointment BEFORE you can be tested for COVID.
Yes
No
If booking a Televisit appointment, I understand that my appointment will be canceled if I do not provide a phone number. I also understand that I must have access to a phone or computer with a working camera, mic, and internet connection.
Yes
No
For clinic visits, I understand my paperwork may be filled out ahead of time at this link:
Care United Patient Forms
Yes
No
Cell Phone Number
Text message confirmation will be sent.
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