Online Check-In Form

THE ONLINE CHECK-IN IS DESIGNED TO DIGITALLY INTAKE INFORMATION FROM PATIENTS.

THE ONLINE CHECK-IN IS NOT AN APPOINTMENT!

COVID-19 TESTING:

IMPORTANT!!: PLEASE FILL OUT THIS FORM FOR COVID-19 RAPID ANTIGEN TEST. THIS FORM IS DESIGNED TO EXPEDITE THE PAPERWORK PROCESS.

*****NO MEDI-CAL OR KAISER ACCEPTED FOR COVID TESTING*********VERIFY IF YOUR INSURANCE IS ACCEPTED IF YOU ARE NOT SURE!

****IF YOU ARE HAVING SYMPTOMS, PLEASE FILL OUT THIS FORM AND CALL US WHEN YOU ARE IN THE PARKING LOT.

TESTING FOR RAPID ANTIGEN IS ON A WALK-IN FIRST COME FIRST SERVE BASIS WHILE SUPPLIES LAST.

VERIFY TESTING CENTER INFORMATION AT 559-324-7001 IF YOU HAVE QUESTIONS OR CONCERNS.

*DOES NOT APPLY TO COVID-19 RT-PCR TESTING! PLEASE CALL FOR FURTHER QUESTIONS.

TELEMEDICINE:

1. Complete the form

2. YOU MUST CALL TO CONFIRM SUBMISSION AND DETAILS (TELEMED AVAILABILITY DEPENDS ON PATIENT VOLUME IN CLINIC!!)

3. Same-day phone call with a healthcare provider. Wait time is dependent on how many patients are signed up for telemed before you.

NO HMOs, MEDI-CAL, OR KAISER FOR TELEMEDICINE. ONLY PPOs ACCEPTED.

Name*

First Name Last Name

Date of Birth*

Format: (MM/DD/YYYY)

Sex:*

MaleFemale

Select a Reason *

Are you a new patient?*

YesNo

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number: *

Format: XXX-XXX-XXXX

Email*

Format: myname@example.com

Preferred Pharmacy

How would you like to pay?*

Driver's License/Identification Card:*

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Front Side Only

Insurance Card: Front Side

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Insurance Card: Back Side

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Terms & Conditions*

I confirm the information provided is true and accurate. Any incorrect information will result in delays.