HELLOMED Walk-In Urgent Clinic Ann Arbor

Patient Check-In Form

Name *

Birth Date *

Phone *

Email *

How did you hear about us?

Address *

Zip code *

Medication Allergy

Preferred Pharmacy *

At Home Medication

Reason for Visit (Main Concern) *

Have you had any exposures such as COVID, Strep, Flu, or Mono?

Yes

Have you been tested for anything in the past week? If so, what and what were the results?

Have you been seen anywhere else in the past week? If so, did they prescribe any medications?

Please upload your ID.

Please upload the FRONT SIDE of your insurance card.

Please upload the BACK SIDE of your insurance card.

I agree to the following terms:

We at HelloMed are required by law to maintain the privacy of and provide individuals with the attached Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. If you would like a copy of the Notice, please ask. HelloMed could send an e-mail or call to inform you of your test result, follow up or news.