Welcome to our
Check-In Portal

• Patient Name*
  First Last
• Cell Phone Number*
• I'm here to see*
  Tamara Loving, MDHaleh Rajaee, MDLaura Walsh, MDLori Van Horn, MDBethanie Cooke, CPNPHolly Frankel, CPNPShellee Halton, CPNPJessica JohnsonOther
• Consent*
  I agree to receive text messages for this service. I understand that message rates may apply and accept any charges.

• Covid Questions

  Please answer the following questions.
• Insurance*
  What is your 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

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• 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

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• Employment*
  Does anyone entering the building currently work in the medical field?
  • Yes
  • No

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• Cough / Allergies*
  Does anyone entering the building have a cough, congestion, fever, shortness of breath, or active seasonal allergies?
  • Yes
  • No

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• Visitor*
  Who is coming into the room with the patient?
• Name
  This field is for validation purposes and should be left unchanged.