Today's Visit Overview

Important Update!

We've moved to Watkinsville Urgent Care at Wire Park!

706-518-6986

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

Does anyone in the family have a heart rhythm problem (patient, parent, grandparent, sibling, aunt, uncle)?

Yes No

If yes, who has the heart rhythm problem?

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):

PATIENT'S medical history that is important for today or that is new:

Please list any updates to FAMILY medical history

Does anyone in the household smoke or use electronic cigarettes inside or outside the home?

Yes 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.

Watkinsville Urgent Care

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

Telephone 706-518-6986
watkinsvilleurgentcare.com
1725 Electric Ave Ste 100D, Watkinsville, GA, 30677