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COVID SIGN IN

Please fill out every section, include your insurance information if you have insurance.

First Name

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Date of Birth

Phone

Subscriber Name and DOB or NA

Insurance Address or NA

Insurance Type or NA

Subscriber ID or NA

It is Complete Wellness/Crimson Network's policy that we collect co-pays and past due balances before you see the doctor. If there are any changes to your insurance since your last visit, please provide that information to the receptionist. We will bill your insurance as a courtesy to our patients, but it is the patient's responsibility to provide accurate insurance information to our office.

I give Crimson Care permission to release my medical records.

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Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate

List any and all reasons for getting your COVID test. Including symptoms, work requirment, travel, and or school.

Pharmacy + Location (Where your prescription will be sent to if needed)

In case of emergency, please contact:

Phone

Signature Initials I certify that the information provided is correct to the best of my knowledge. I will not hold Complete Wellness/Crimson Network, its health providers, or its employees responsible for any errors or omissions that I may have made in completing the information on this form. I hereby voluntarily consent to treatment for me or my dependent at Complete Wellness/Crimson Network and authorize such treatments, examinations, medications and diagnostic procedure (including, but not limited to the use of lab and radiographic studies) as ordered by its providers. I hereby voluntarily consent to the taking of photographic images for treatment purposes only (wound care progression, documentation of rashes, etc.) as ordered by such providers.

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