Section 1 of 1
Contact information
If you have an emergency stop now and call 911/ si tiene emergencia ahora, pare y llame al 911
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Are you an adult or emancipated minor? Es adulto o menor de edad emancipado?
Are you an adult or emancipated minor? Es adulto o menor de edad emancipado?
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No
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Email
URL
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973-919-6200
973-919-6200
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Where do you need services? Donde necesita el servicio?
Where do you need services? Donde necesita el servicio?
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In the medical office 3300 Hudson Ave, Union City, NJ 07087/ en la clinica de Union City
At home as I am unable to access the clinic facility/ en casa ya que no puedo llegar alla
In a community setting/en un sitio comunitario
At work/ En el trabajo
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How can we help you?/ Como le podemos ayudar?
How can we help you?/ Como le podemos ayudar?
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What kind of service(s) do you need? Que servicios necesita?
What kind of service(s) do you need? Que servicios necesita?
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Physical check up/ Chequeo general
Sick visit/ Chequeo por enfermedad
Immigration medical/ Examen medico para inmigracion
Gynecology exam/ Examen ginecologico
Covid or flu vaccine/ Vacuna de Covid o de la gripe
Monkeypox vaccine/Vacuna de Monkeypox
Other Vaccine/ Otra vacuna
Work physical/ Fisico para trabajo
School physical/ Fisico para la escuela
Telehealth/Medicina Virtual (Telemedicina)
Adolescent health/Salud para adolescente
Refill medications/ Renovar mis medicinas
Diabetes or high blood pressure check/ Monitoreo de diabetis o la presion
Covid-19 test or treatment/ Prueva or tratamiento de Covid
Other:
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What day works best? /Que dia es mejor?
What day works best? /Que dia es mejor?
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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What times?/ Que horas tiene disponible?
What times?/ Que horas tiene disponible?
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Date
Time
Monday/Lunes
Tuesday/Martes
Wednesday/Miercoles
Thursday/Jueves
Friday/Viernes
Saturday/Sabado
Sunday/Domingo
Column 8
Column 9
Column 10
Column 11
Afternoon/PM
Rows
1.
Afternoon/PM
2.
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Columns
Monday/Lunes
Tuesday/Martes
Wednesday/Miercoles
Thursday/Jueves
Friday/Viernes
Saturday/Sabado
Sunday/Domingo
Column 8
Column 9
Column 10
Column 11
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If you have health insurance, which one?/ Si tiene seguro de salud, cual es?
If you have health insurance, which one?/ Si tiene seguro de salud, cual es?
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Medicare, Clover, Medicare Advantage
Medicaid, Horizon NJ Health, Family Care, United Community Plan
Other Medicaid
Commercial BC/BS
United Healthcare PPO
Cigna
Aetna
Qualcare
Emblem
Other:
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Do you have charity care at a hospital?/ Tiene charity care de un hospital?
Do you have charity care at a hospital?/ Tiene charity care de un hospital?
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Yes/Si
No
Maybe, but may be expired/ quizas este vencido
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If not insured, do you wish to apply for salary fee scale fee for service?/ Si no tiene seguro medico, desea aplicar para cobro segun su salario?
If not insured, do you wish to apply for salary fee scale fee for service?/ Si no tiene seguro medico, desea aplicar para cobro segun su salario?
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Maybe/ Quizas
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