New Participant InformationDate* MM slash DD slash YYYYLast Name*First Name*Middle NameAddress*City*State*Zipcode*SSNOccupationDate of Birth* MM slash DD slash YYYYAge*Gender* Male Female Other Telephone*Martial Status* Single Married Other Email* State Issued IDAccepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.Location* Lauderhill Hollywood Emergency Contact Name*Contact Relation to You*Contact Phone Number*Medical InformationAllergies* Past Medical Problems* Current Medications* Past Surgeries (include C-Sections and year)* Family Medical History* Physician NamePhoneLast Menstrual Period MM slash DD slash YYYYNumber of Times PregnantNumber of ChildrenDo You Smoke* Yes No Do You Drink Alcohol* Yes No Do You Take Drugs* Yes No InsuranceSubscriber (if different from above)Insurance namePolicy#Subscriber's DOB MM slash DD slash YYYYInsurance CardPlease add the front and back of the insurance card. Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 2.PharmacyPharmacy NameAddressPhoneHow did you find out about us? Select All Internet Family Member Radio Friend Covid-19 Screening ToolHave you traveled outside of the USA in the last 14 days?* Yes No Have you traveled within the USA in the last 14 days?* Yes No Been on a cruise ship within the last 14 days?* Yes No Attended any gatherings with more than 100 people within the last 14 days?* Yes No Been in close contact with a person known to have the 2019 Novel Coronavirus?* Yes No Have you been asked to self-quarantine?* Yes No Had a fever, cough, or shortness of breath?* Yes No Any new onset cold symptoms, runny nose, sore throat, or other signs of a respiratory infection?* Yes No Any new onset eye infection?* Yes No Any new onset chills, muscle aches and persistent headaches?* Yes No Any loss of taste or smell?* Yes No HiddenCovid Screen DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SignatureSign Here*Consent for TreatmentConsent*I voluntarily consent to the rendering of care, including treatments, administering anesthetics, and the performance of diagnostic procedures. I understand that I am under the care and supervision of Medix Urgent Care Center (MUCC) or Medix Family Health Center (MFHC) and its Physician, NP, or PA. I hereby assign payment directly to MUCC/MFHC, accepting this assignment of medical benefits applicable and otherwise payable to me but not to exceed the provider's regular charges. I understand that I am responsible for the charges not covered by this assignment or for any other charges which the insurance carrier declines to pay. It is further agreed that any credit balance resulting from payment of insurance or other sources may be applied to any other accounts owed to said providers by the insured or family. The provider may disclose all or part of the patient's record to any person or corporation which is or may be liable under a contract to the provider or to a family member or employer of the patient of the provider's charges, including but not limited to Insurance companies, Medicare, Medicaid, Worker's Compensation carriers, welfare funds or patients employer. I acknowledge that I have received a copy of the Notice of Privacy Practices from MUCC/MFHC which describes how my health information may be used or disclosed. I understand that I should read it carefully and that it may change at any time. I agree to the privacy policy.
