Patient Check In Information
Patient Check In Information
Email *
As we have recently announced the Ely Community Health Center has migrated to a virtual Telehealth operation indefinitely. These Telehealth evaluations will be performed each Thursday evening between the normal clinic hours of 5:30pm to 7:00pm. This decision was made to protect the health and safety of our medical and other volunteers. We hope you understand.
Please complete this patient appointment registration form completely and we will confirm your appointment and the scheduled time upon receipt. All appointments are made based on a first come first served basis so please provide all the information requested.
Patient's First Name *
Patient's Last Name *
Please select which time frame you would like to have your appointment scheduled for: *
Required
Please describe the reason that you would like to schedule this appointment so we can be prepared before we contact you. *
Have you received care here before? *
Marital Status *
Date of Birth *
MM
/
DD
/
YYYY
What is your racial background? *
Required
Gender *
Mailing Addresses *
City *
State *
Zip Code *
Phone number *
Is the above phone number a mobile phone? *
Who is your emergency contact? *
What is the phone number of your emergency contact? *
Do you have health insurance *
Do you have access to dental care? *
Are you employed? *
Are you a Veteran? *
Do you have a living will *
Number of people in your household *
What is your approximate monthly income? *
I have concerns about and/or would like help with:
Please tell us how you found us and decided to visit the Ely Community Health Center
Is the patient under 18 years old? *
If the patient is under 18 years old, we will need to send you an authorization form in order to provide these services. Please have the legal guardian complete the authorization for treatment form and return it to us before the scheduled appointment.
Have you ever had any of the following? *
Required
If you are a female, have you ever had:
What is your smoking status? *
If you are a former smoker, please indicate the approximate date you quit smoking.
MM
/
DD
/
YYYY
If you are a smoker, are you interested in quitting?
Clear selection
Are your immunizations up to date? *
Have you been checked for diabetes within the past year? *
If you are over 50, have you been screened for colon cancer within the past five years? *
Do you have any concerns about: *
Required
Do you have any known allergies? *
Please describe your allergies that you have. Please list any list drug names you are allergic to and the reaction
Please describe below the medications that you are taking, include the prescription name, dosage, frequency and reason that you are taking the medication.
Medication 1 - Please include the prescription name, dosage, frequency and reason that you are taking the medication.
Medication 2 - Please include the prescription name, dosage, frequency and reason that you are taking the medication.
Medication 3 - Please include the prescription name, dosage, frequency and reason that you are taking the medication.
Medication 4 - Please include the prescription name, dosage, frequency and reason that you are taking the medication.
Medication 5 - Please include the prescription name, dosage, frequency and reason that you are taking the medication.
Thank you for filling out the registration information request. We will schedule your appointment as quickly as we can.
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