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2:30pm
3:00pm
3:30pm
First Name
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Last Name
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Date of Birth
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What is your reason for the visit? Cual es el motivo de la visita?
Adult Immunizations
AHV
Asesoramiento planificacion familiar
Blood Pressure check
C1st
Chequeo de salud para ninos
Child Health Check
Control de presion arterial
Deberes
Deteccion de Escoliosis
Deteccion Metabolica del recien nacido
Deteccion SSI
Evaluacion de edadeEtapas dei desarrollo
Examen anual del paciente
examen de nueva paciente
Examen de transmision sexual
Examenes de audicion, vision y dental
general lab (with a Doctor's order)
Hearing, Vision, Dental Screening (HVD)
Immunizations
Immunizations and HVD Screening
Influenza vaccine
Laboratorios generales (orden medica)
Lice Check
metodos de anticonceptivos
New Birth Control Appointment
Newborn Metabolic Screening (PKU)
Pfizer Covid-19 Vaccine
Pregnancy test (not Pregnancy Medicaid)
PrEP
Prueba de embarazo
Prueba de sangre para tuberculosis
prueba de tuberculosis
resultado de tuberculosis
Return Patient Birth Control (ocs, depo)
Revision de cabeza para piojos
Scoliosis Screening
SSI Screening
STD testing/exam
STD Treatment
TANF Family Planning Counseling
TB blood test QuantiFERON Gold
TB skin test (PPD) (no Thursday appts)
TB skin test (PPD) reading
Tratamiento de transmision sexual
Una cita breve
Vacuna contra la Influenza
vacuna Pfizer contra el COVID-19
Vacunacion de adulto
Vacunas para ninos
Women's Health New Patient Exams
Women's Health Return Annual Exam
WWBF
Were you referred to us? If so, who referred you? Te refirieron a nosotros? Si es asi, quien to refirio?
Preferred Language - Enter 1 for English, 2 for Spanish * must be entered in order receive required forms for your appointment Idioma preferido: ingrese 1 para inglés, 2 para español * debe ingresarse para recibir los formularios requeridos para su cita
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Enter the name of your insurance company and policy number. Ingrese el nombre de su compañía de seguros y el número de póliza.
Do you have Health Insurance? ¿Tiene Seguro Médico?
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Yes
No
Did you receive a pink annual reminder letter in the mail? Recibiste una carta rosa de recordatorio anual por correo?
Yes
No
By entering your cell phone number, you are acknowledging consent to receive text messages. Al ingresar tu número de celular, estás reconociendo tu consentimiento para recibir mensajes de texto.
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Cell Phone Number
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Text message confirmation will be sent.
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