Sandy Crest / Coverley

Online Doctors Visits

Are you a patient of Sandy Crest/ Coverley Medical Centre?
Yes
No
Patient Information
Choose your clinic?
Coverley Medical Centre
Sandy Crest Medical Centre
Date:
2020/06/04
Time:
06:15:15am
Mr: Mrs: Miss: Dr:
Last Name:
M/I:
First Name:
Date of Birth:
Email Address:
Home Tel. No.:
Cell. No.:
Work No.:
Ext.:
Payment Method:
Credit Card: Online Bank Transfer:
Health Information
What is your complaint today?
How long have you been experiencing these symptoms?
Telemedicine, although a useful convenience is not a replacement for face to face medicine.
Do you consent to a doctors consultation via telemedicine ?
Yes, I acknowledge and consent to a medical consultation via telemedicine.
No, I do not consent to a telemedicine consultation.
Do you prefer a video or voice only consultation?
Video
Voice Only

By checking the box to the left, I understand that my information will be stored by Sandy Crest Medical Centre on their online databases and paper form.


Patient Information
Date:
2020/06/04
Time:
06:15:15am
Which location do you wish to be registered with?
Sandy Crest Medical Centre Sunset Crest St James.
Coverley Medical Centre The Villages at Coverley Christ Church
Mr: Mrs: Miss: Dr:
Last Name:
M/I:
First Name:
Date of Birth:
Nationality:
Address:
Home Tel. No.:
Cell. No.:
Work No.:
Ext.:
Email Address:
ID#:
Occupation:
Employer:
For Vistiors
Local Address:
Local Tel No:
Preferred Method of contact:
Home: Cell: Email: Work:
Other:
Next of Kin:
Contact:
Health Information
What is your complaint today?
How long have you been experiencing these symptoms?
Allergies:
Telemedicine, although a useful convenience is not a replacement for face to face medicine.
Do you consent to a doctors consultation via telemedicine ?
Yes, I acknowledge and consent to a medical consultation via telemedicine.
No, I do not consent to a telemedicine consultation.
Do you prefer a video or voice only consultation?
Video
Voice Only
Insurance Information
Insurance Carrier:
Sagicor: ICBL: Massy: Guardian: Resolution Life: Colonail: Pan American: Brydens: JIPA/COB:
Payment Method:
Credit Card: Online Bank Transfer:

By checking the box to the left, I understand that my information will be stored by Sandy Crest Medical Centre on their online databases and paper form.