How can we help you today?

Name

Birth Date

Email

Phone

How did you hear abouth us?

Address

Medication Allergy

Preferred pharmacy

At Home Medication

Please tell us any symptoms you may experiencing.

General - Fever, fatigue, body aches

Eye - Pink eye, Stye etc

Ear, Nose & Throat - Sore throat,Ear pain, Sinus congestion

Respiratory - Breathing problem

Cardiovascular - Chest pain, circulation issue

Gastrointestinal - Vomit, Diarrhea, abdominal pain

Genitourinary - frequency, urgency, pain etc

Musculoskeletal - pain, limit of motion, injury

Neurologic - headache, dizziness

Skin and allergic reaction

Others

Others - Please explain

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

Yes

No

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 prescreibed any medications?

Thanks for checking-In. See you in a minute!

(734) 210 - 1122

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