Check-In Prior to Appointment
Please fill in all fields and add Insurance/ Photo ID cards before submitting.
CHECK-IN
PH: 845-215-9567 FAX: 845-215-5980
DATE
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
PATIENT'S NAME
DOB
-
Month
-
Day
Year
Date
PHONE
EMAIL
example@example.com
ADDRESS
CHIEF COMPLAINT
Preferred Pharmacy
Guardians Name
Height
Weight
Test
Rapid
PCR
Other
Allergies
MEDICAL
History
Family History
Medications
Past Surgeries
Smoke
Pack
Drug Use
Drink
Pregnant
Last Menstrual Cylcle
Vaccination
1st DOSE
Fully
Medical Insurance ID and Picture ID
Browse Files
Drag and drop files here
Choose a file
Front and Back of ID's
Cancel
of
Submit
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