Today's Visit Overview

Please explain how we can best serve you today.

Please correct the errors described below.

Patient Name

Email address

Age

Date of Birth

mm/dd/yyyy format

Mobile or Best Phone

Which pharmacy would you like to use today if a prescription is to be sent electronically?

Name of pharmacy and City, State

Medicine or Food Allergies

Current Medications

Main reason for today's visit (chief complaint)

When did the problem/symptoms begin?

Please choose an answer for each question (If applicable):

Have you had any of the following symptoms DURING THIS ILLNESS?

Fever or chills

Body Aches

Red eyes or eye discharge

Runny or stuffy nose

Sore throat

Ear pain

Cough

Wheezing or difficulty breathing

Chest pain

Nausea/Vomiting

Diarrhea

Abdominal pain

Frequent urination

Pain with urination

Blood in urine

Joint pain

Rashes

Headaches

Patient's past medical history that is important for today:

Any smokers who live in the home?

Yes (me) Yes (other family) No

For females, when was your last menstrual period?

In-Office visit or telemedicine?

In-Office Telemedicine

Have there been any changes to your insurance or contact information since your last visit?

Yes No

The medical directors and/or providers regularly pray for patients who visit the practice.   Would you like them to pray for you/your child when they are praying for patients?

Yes No

Please upload current copies of your insurance ID card (front and back) if we do not already have them on file.

Add file

Please upload a file

Your information will be encrypted.

PrimeTime Clinics

If you have any questions about the form please call the office number below. General questions about the clinic can be sent to info@primetimeurgentcare.com

Telephone 706-705-4543x1
primetimeurgentcare.com
1618 Mars Hill Rd Suite A, Watkinsville, GA, 30677

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