Questions

• Insurance*
  What is your child's current insurance
  AETNA –HMO, PPO, OPEN ACCESSANTHEM BCBS PPOANTHEM FEDERAL BCBSANTHEM HEATHKEEPERS (PPO ONLY)CAREFIRST PPO, HMOCIGNA PPO, HMOFIRST HEALTHGEHAGOLDEN RULEMAILHANDLERSOPTIMA PPO, HMO (NON MEDICAID PLANS ONLY)PHCSTRICARE SELECT (STANDARD ONLY)UNITED HEALTH CARE PPO, HMOOther
• Covid Contact*
  Has anyone coming in for this appointment been in direct contact with a positive Covid patient / or one being tested awaiting results
  • Yes
  • No
• Employment*
  Does anyone entering the building currently work in the medical field?
  • Yes
  • No
• Cough / Allergies*
  Does anyone entering building have cough, congestion, fever, shortness of breath, or active seasonal allergies?
  • Yes
  • No
• Visitor*
  Who is coming into the room with client?
• Phone
• Email
  This field is for validation purposes and should be left unchanged.