In-Office Screener

In-Office Screener

+ Contactless Check-In
Please complete this form 36hrs - 24hrs prior to your scheduled appointment, or your appointment may be rescheduled.

🙌🏽 Introducing Contactless Check-In

We don't know what to expect this Cold and Flu season but we're trying to be prepared for whatever comes our way - as best we can - to better serve you.

As such we are modifying our Check-In process to help promote physical distancing during the Cold and Flue season. We will continue to make changes in small increments to further these goals.

We believe this and upcoming changes will allow us to decrease check-in and check-out times, and we hope this results in a more positive experience for all of us.

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Insurance Cards: We will no longer be scanning insurance cards in office.

Instead, upload a copy of the front of your primary (and secondary) insurance card(s) below.

Include the back of your card(s) if this is your first visit under the policy or you are a New Patient.

***

👀
PS Private Browsing Mode will prevent this form from being submitted.

Sincerely,

The Office of Dr. Swamy
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Date of Scheduled Appointment

Month Day Year
Date
File Upload: Choose from the following options: *
File Upload: Are you a New Patient or Established Patient

Established Patient New Patient
File Upload Established Patient: Has your insurance information changed since your last visit?

Yes, I have new insurance. No, my insurance has not changed since my last visit.
Upload a copy of the FRONT and BACK of your Insurance Card *

Browse Files

Cancel of
Upload a copy of your Driver's License or Photo ID.

Browse Files
*This is optional. If you prefer you may provide a copy when you arrive for your first visit. Cancel of
Upload a copy of the FRONT of your Insurance Card *

Browse Files

Cancel of
Upload a copy of the FRONT and BACK of your Insurance Card *

Browse Files

Cancel of
Covid Screener Questions
Have you experienced any of the following within the last 2-4 weeks? Check all that apply. *

Coughing Fever or Chills Shortness of Breath or Difficulty Breathing Fatigue Muscle or Body Aches Headache New loss of Taste or Smell Sore Throat Congestion or Runny Nose Nausea or Vomiting Diarrhea None of the Above
Have you travelled outside of Austin within in the past 2-4 weeks? *

Yes No
If yes, please describe Where, When, How, and Why you travelled. *
Have you attended any gatherings within in the past 2-4 weeks with individuals from different households? *

Yes No
Have you been exposed to anybody who has tested positive to Covid-19? *

Yes No
I understand, depending on the answers provided to the questions above the office may be contacting me for more information and/or to switch my appointment to a virtual telemedicine visit. *

Yes
Signature *

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In-Office Screener

Please complete this form 36hrs - 24hrs prior to your scheduled appointment, or your appointment may be rescheduled.

Covid Screener Questions