Online Check-In Form

THE ONLINE CHECK-IN IS DESIGNED TO DIGITALLY INTAKE INFORMATION FROM PATIENTS UNABLE TO ENTER THE CLINIC OR FOR TELEMEDICINE RELATED PURPOSES.

THE ONLINE CHECK-IN IS NOT AN APPOINTMENT!

COVID-19 TESTING:

IMPORTANT!!: DO NOT FILL OUT THIS FORM TO RESERVE A COVID-19 RAPID ANTIGEN TEST UNLESS INSTRUCTED BY STAFF TO DO SO.

ALL RAPID TESTING IS DONE ON A WALK-IN BASIS UNTIL WE REACH OUR LIMIT OF TESTING PER DAY.

YOU MUST WALK-IN TO CONFIRM A TIME FOR RAPID ANTIGEN TESTING.

TESTING STARTS AT 8AM. FIRST COME FIRST SERVE.

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

TELEMEDICINE:

1. Complete the form

2. Call to confirm submission and be processed

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

NO HMOs, MED-ICAL, OR KAISER FOR TELEMEDICINE. ONLY PPOs ACCEPTED.

REGENERON MONOCLONAL ANTIBODY THERAPY TELEMEDICINE:

DO NOT FILL OUT THIS FORM UNLESS INSTRUCTED BY STAFF. PLEASE CALL TO INQUIRE ABOUT OUR PROTOCOLS.
Name *

First Name Last Name
Date of Birth *
Format: (MM/DD/YYYY)
Sex: *

Male Female
Select a Reason *
Are you a new patient? *

Yes No
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: *

Front Side Only
Cancel of
Insurance Card: Front Side

Cancel of
Insurance Card: Back Side

Cancel of
Terms & Conditions *

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

THE ONLINE CHECK-IN IS DESIGNED TO DIGITALLY INTAKE INFORMATION FROM PATIENTS UNABLE TO ENTER THE CLINIC OR FOR TELEMEDICINE RELATED PURPOSES.