Covid 19 Oral Anti-Viral Appointment Request and Registration
Patient Name
*
First Name
Last Name
Patient Birth Date
*
Please select a month
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Day
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Year
Patient Sex
*
Please Select
Male
Female
Ethnicity
Caucacian
Black or African American
Native Hawaiin and other pacific islander
American Indian and Alaskan Native
Asian
Hispanic
Patient Height (inches)
*
Patient E-Mail
*
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a positive PCR test?
Was your COVID test performed at a clinic/lab, or was it an at home test
I had a positive test that was performed at a clinic or laboratory
I had a positive at-home test
Patient Weight (Ib)
*
What date did your symptoms start?
What therapeutic COVID medication do you need?
Paxlovid (oral medication)
Molnupiravir (oral medication)
Patient Medical History
Do you have a primary care physician? Please lease enter their name below and tell us which health system they belong to.
Please check all that apply
History of Cancer
Immunosuppression
Type 1 or Type 2 Diabetes
Heart Disease
High Blood Pressure
Chronic Kidney Disease
chronic Liver Disease
Neurological Disorders
Chronic Lung Disease
Age>65years
BMI>35 years
I am currently pregnant
Other illnesses:
Please list any Operations and Dates of Each
Include other comments regarding your Medical History
Please list your Current Medications
Please list any drug allergies
Please tell us what medical conditions your family has.
Date
-
Month
-
Day
Year
Date
Health and Lifestyle Evaluation
Exercise
None
1-2 days
3-4 days
5+ days
Alcohol Consumption
None
A few times a week
A few times a month
Daily (1-2 drinks)
Daily (3-4 drinks)
Daily (5 or more drinks)
Diet
I have a strict diet (Gluten Free, Vegetarian, Vegan, Paleo etc.)
I have a generally healthy diet with occasional processed foods
I do not have a particular diet
Caffeine Consumption
1-2 cups/day
3-4 cups/day
5 or more cups/day
I don't use caffeine
I rarely drink caffine
Tobacco Use
None
Occasionally
0-1 pack/day
1-2 packs/day
2+ packs/day
My signature below confirms that I understand it is my responsibility to know my heath insurance coverage prior to my appointment, and if I have questions about my coverage, I must call my insurance company prior to my appointment with Minneapolis Health Clinic. If there is a remaining balance after the claim has been processed through my insurance, I assume financial responsibility of the services received from Minneapolis Health Clinic and will pay my medical bill in a timely manner. If any payment is needed at the time of my visit, I understand it will be needed at the time of my arrival.
Insurance Information
*
Insurance Company Name, ID number, and Group number
Please upload a picture of your insurance card
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Signature
Date
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Month
-
Day
Year
Date
If person signing is not the patient, state the relationship, your age and reason for representation.
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