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HIDDEN Null

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HIDDEN Note Reason

AAA Entry Unique ID

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Show clinic dropdown

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Traffic Source

this variable shows where traffic came to this form from. Query string variable is checkinid

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Arrived

this variable is set to 4 when patient has arrived in the parking lot. the querystring variable is arvd. Default value is 0

If you have issues checking-in - Please go in and ask the front desk or ask over the online chat

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Current Hour

hideme {current_hour}

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Current Minutes

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HourFraction

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Today Date

captures the date of entry for use in calculations

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Tomorrow Date

captures the date of entry for use in calculations

You are here for the Arlington clinic

FRONT DESK Registering for the Arlington clinic

Select Clinic(Required)

Select which of our locations you would like to visit

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HIDDEN Clinic

the hidden value of the url code for the clinic selected. USE THIS FOR ALL SELECTION OF CLINIC

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HIDDEN Hospital ID

HIDE ME

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HIDDEN Max Clinic Visits Today

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HIDDEN Front Desk Phone

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Count of bookings today

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Count of bookings tomorrow

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Spots left today

There are 5 remaining spots today at Arlington clinic.

The Arlington clinic is booked up for today - check the schedule for tomorrow or check our other clinics.

We open more spots every morning so check back tomorrow morning as well

DUE TO WEATHER- THIS CLINIC IS CLOSED THE REMAINDER OF THE DAY

We will reopen tomorrow morning at 8am

DUE TO HOLIDAY - THE CLINICS ARE CLOSED We will reopen tomorrow morning at 8am

DUE TO BAD WEATHER - THIS CLINIC IS OPENING ON FEBRUARY 25th AT 10 AM

Please check our website for information on tomorrows hours and closing information.

Clinic is currently closed -
Don't worry - We can still book you for when we are open!

We are open Mon - Sat 8am-8pm and Sun 12pm-8pm

Clinic is nearing closing time (8pm)

Don't worry - If you are in the parking lot BEFORE 8pm (even if you completing your registration) we will see you. When you arrive, pop into the lobby to let us know you are here.

At 8pm we stop seeing new patients who are not here at the clinic before 8pm.

You Are At The Arlington Clinic

Car color

Make and model of car

Please go ahead into the clinic to let the front desk know you are here and completing your paperwork.
You can still complete it in your car, but this way we know you are here to be seen near closing.

IF YOU HAVE ALREADY REGISTERED FOR TODAY'S VISIT - Enter The 9 digit Visit ID (code starting with Z8 or Z9)

You receive this Visit ID AFTER SCHEDULING AND COMPLETING REGISTRATION.

Is the patient in emergency medical distress or having a true medical emergency?

No, patient is not in medical distress

Yes, patient is in medical distress or having a true medical emergency

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Visit ID Verification

USED TO SET NEW REGISTRATION FLAG

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Visit Block Time

You are CHECKING IN from an existing registration

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New Registration Flag

1=new registration, 0 or empty means existing registration

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HIDDEN Times limit today

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HIDDEN Times limit tomorrow

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HIDDEN VISIT ID From Lookup

EMERGENCY

YOUR CONDITION IS ACUTE AND REQUIRES IMMEDIATE ATTENTION

Please proceed directly into the clinic with your ID and insurance card.

YOUR CONDITION IS ACUTE AND REQUIRES IMMEDIATE ATTENTION

Please stop and seek emergency medical care or dial 911

Patient Information

Patient Name(Required)

First Last

Patient Date of Birth(Required)

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Patient Age

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HIDDEN Patient (or parent for minors) Mobile Phone

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HIDDEN Patient (or parent for minors) Email

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HIDDEN REG Patient Address

Street Address Address Line 2 City State ZIP Code

Is the patient a new or existing patient at any of our clinics?(Required)

Patient is New - They have not been to any CommunityMed clinic before

Patient is an existing patient

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HIDDEN Patient New

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PatientGUID

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HIDDEN LOOKUP Previous Visit

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Last Visit Date

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Days since last visit

Has any of the patients insurance coverage details or address details changed since your last visit(Required)

Yes, I have changes I need to update

No, all of the information is the same

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New Patient State

= 1 is patient is new, 0 = patient is existing, no entry means patient is existing

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HIDDEN PREVIOUS Patient Address

Street Address Address Line 2 City State ZIP Code

APOLOGIES - We changed our registration system

EITHER we do not have the patient in our new system OR the patient's last visit was over a year ago. We will go ahead and complete a new patient record in our new system. Thanks for your patience

We found your record from the visit

Patient Details
Patient Address(Required)
Street Address Address Line 2 City State ZIP Code

Patient Biological Sex(Required)

Male

Female
Patient Marital Status(Required)

Married

Single

N/A
Last 4 Digits of Social Security Number

Family Physician

Preferred Pharmacy

Description of Pharmacy location

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)
Because the patient is a minor, they require an adult who is legally able to sign permission forms for the patient (usually the parent or guardian). The remaining information on this page is to be completed by this adult. The guarantor is the Adult, responsible for the Minor, who is signing the form.
Parent Name (Guarantor)
First Last
Your Relationship to Patient

Parent/Step Parent

Spouse

Other

Parent Date of Birth(Required)
We need this to verify your identity
MM slash DD slash YYYY

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Parent age
current age, no decimal needed
Your Biological Sex(Required)

M

F
Your Legal Marital Status

Single

Married
Guarantor Address
Check here if Patient lives at same address as Patient
Your Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Method of Payment
How will you be paying for the visit today?

Patient has insurance

Patient does not have insurance and will be paying cash
NOTE: We do not accept Medicaid.
We are not currently credentialed with any forms of Medicaid
Insurance
Bring your insurance card into the clinic when you are called in for your visit.
Patient relationship to the Policy Holder(Required)
Describe Other Policy Holder Relationship(Required)

Insurance Coverage Details
Policy Holder Name
First Last
Policy Holder Birthdate(Required)
MM slash DD slash YYYY

Policy Holder Email

Policy Holder Social Security Number

Policy Holder Address - check if true
Policy Holder (the person primarily insured) lives at the same address as Patient
Policy Holder Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Policy Holder Cell Phone

PRIMARY Insurance Policy Details
Primary Health Insurance Company Name
Start typing the name of your insurance provider and the list will be filtered, Select Other if your insurance is not listed
PO Box or Address on the back of your insurance card
OTHER Health Insurance Company Name if NOT LISTED ABOVE

OTHER Insurance Company ADDRESS if NOT LISTED ABOVE

Insurance Member Number(Required)

Insurance Group Number

Insurance Group Name

Patient is also covered by a SECONDARY or SUPPLEMENTAL health insurance policy

Yes

No
please bring in your secondary insurance card as well

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Hidden Visit Date Selected
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HIDDEN Pick Visit Time

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HIDDEN Pick Visit Time NAME

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HIDDEN Patient Name
First Last
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HIDDEN Patient Date of Birth
MM slash DD slash YYYY

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HIDDEN reformatted Patient Date of Birth
YYYY dash MM dash DD

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HIDDEN Patient Address
Street Address Address Line 2 City State ZIP Code

System Visit ID
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HIDDEN Next Forms Reg State
state machine 2= new reg, old patient 4=old reg, new patient 6=new reg new patient
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Hours from now
How many hours from now is the appointment time
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HIDDEN Days from today
how long from now is appointment
Stay in the Parking Lot
YOUR VISIT IS LESS THAN 2 HOURS FROM NOW
Please stay in the parking lot and wait. Sometimes we can see you faster than your scheduled block SINCE YOU ARE HERE.
Leave and Return
YOUR VISIT IS 2 OR MORE HOURS FROM NOW
You can choose to stay in the parking lot and wait. Sometimes we can see you faster than your scheduled block IF YOU ARE HERE.
OR
You can leave and be back in the parking lot AT THE BEGINNING OF YOUR TIME BLOCK.
Select below to let us know what you want to do
Stay and wait or leave?

I want to STAY IN THE PARKING LOT through the block time

We will LEAVE and RETURN BEFORE THE BEGINNING OF THE SCHDULED BLOCK TIME
WHEN YOU RETURN
Scan the QR code/go to the check in link again and enter your 9 digit Visit ID (starts with 99) that you receive in email and text when your check-in is complete. Then WAIT IN YOUR VEHICLE and ANSWER YOUR PHONE - we will call you when it is your turn.
Next Step
We need a little more detail on your work injury
Lets get you a spot in line - we reserve spots in blocks - click Next to continue

PLEASE NOTE: IT MAY TAKE UP TO 30 SECONDS FOR THE NEXT PAGE TO LOAD
Lets go over some of the required info you need with you today for a DOT Physical, then we will grab you a spot in line. Click Next to continue
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Create Clockwise Flag
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Place in line

You are here for the Arlington clinic

You are here for the Arlington clinic

FRONT DESK Registering for the Arlington clinic

The Arlington clinic is booked up for today - check the schedule for tomorrow or check our other clinics.

DUE TO WEATHER- THIS CLINIC IS CLOSED THE REMAINDER OF THE DAY

DUE TO BAD WEATHER - THIS CLINIC IS OPENING ON FEBRUARY 25th AT 10 AM

Clinic is currently closed - Don't worry - We can still book you for when we are open!

Clinic is nearing closing time (8pm)

You Are At The Arlington Clinic

You are CHECKING IN from an existing registration

EMERGENCY

YOUR CONDITION IS ACUTE AND REQUIRES IMMEDIATE ATTENTION

YOUR CONDITION IS ACUTE AND REQUIRES IMMEDIATE ATTENTION

Appointment Issue - Canceled Appointment

Our records indicate this appointment was cancelled

Appointment Issue - Still on Wait List

Our records indicate this appointment is wait listed and does not have a time assigned yet

Registration Code Issues

ERROR WITH YOUR VISIT ID

YOU SELECTED AT REGISTRATION is below - YOU ARE CURRENTLY AT Arlington

Registration Code Issues

ERROR WITH YOUR DATE OF VISIT

ERROR: Your registration was for a different day

Patient Information

PLEASE VERIFY CELL PHONE AND EMAIL BELOW

Patient Registration

Note that for your protection, Communitymed follows medical best practice and performs a medical exam on all COVID testing patients. All COVID tests require a medical office visit

WE STOP DRUG TESTING AT 6:00pm

Please change answer above on "Reason for Visit" to Injury Visit in order to be seen for a workplace injury

WE WILL SEND YOU THE UIL FORM

NOTE:

IMPORTANT NOTE ON CONCUSSIONS:

Important Vision Test Info:

IMPORTANT CARDIAC NOTE:

YOUR CHILD IS UNLIKELY TO PASS THE SCHOOL PHYSICAL

Patient Information

APOLOGIES - We changed our registration system

EITHER we do not have the patient in our new system OR the patient's last visit was over a year ago. We will go ahead and complete a new patient record in our new system. Thanks for your patience

We found your record from the visit

Patient Details

YOUR INFO AS THE ADULT RESPONSIBLE FOR MINOR PATIENT (GUARANTOR)

Method of Payment

NOTE: We do not accept Medicaid.

We are not currently credentialed with any forms of Medicaid

Insurance

Insurance Coverage Details

PRIMARY Insurance Policy Details

Stay in the Parking Lot

YOUR VISIT IS LESS THAN 2 HOURS FROM NOW

Leave and Return

YOUR VISIT IS 2 OR MORE HOURS FROM NOW

WHEN YOU RETURN

Next Step

We need a little more detail on your work injury

Lets get you a spot in line - we reserve spots in blocks - click Next to continuePLEASE NOTE: IT MAY TAKE UP TO 30 SECONDS FOR THE NEXT PAGE TO LOAD

Lets go over some of the required info you need with you today for a DOT Physical, then we will grab you a spot in line. Click Next to continue

Clinic is currently closed -
Don't worry - We can still book you for when we are open!

Lets get you a spot in line - we reserve spots in blocks - click Next to continue

PLEASE NOTE: IT MAY TAKE UP TO 30 SECONDS FOR THE NEXT PAGE TO LOAD