SmartDocMD Coronavirus/COVID-19 Risk Assessment Tool

On this page you will be asked to list your/the patient’s name, address and other demographic information.

This is EXTREMELY IMPORTANT to let your local hospital system know how to contact you.

Please provide the following required info for processing so your local hospital system has this information and can contact you if needed:

Patient's Full Name*

First Middle Last

Patient's Email*

Patient's Phone*

Patient's Date of Birth*

Patient's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Select this box IF you are answering this form for someone else and you are NOT the patient.

Select this box IF you are answering this form for someone else and you are NOT the patient.

Your Full Name*

First Last

Relationship to Patient*

Are you this patient’s legal guardian?

Yes
No
I don't know

Are you this patient’s healthcare power of attorney?

Yes
No
I don't know

Please enter the hospital or health care system that will contact you (this may be the health care system that you have an upcoming visit with or that requested the sending of this form to you. If you are unsure please enter the name of the health system you use most often or that your doctors/providers are a part of):*

What is your preferred method of contact by your local hospital system?*

Email
Text Message
Phone Number

Please enter the email address you would like to be contacted by your local hospital system with:*

Please enter the phone number you would like to receive texts messages at by your local hostpital system:*

Please enter the phone number you would like to receive phone calls at by your local hostpital system:*

I agree to the privacy policy and terms of service, as viewed in the link below.*

Please check this box if you agree to our privacy notice.

SmartDocMD Privacy Policy & Terms of Service

Please review your information carefully and click the button to submit. If you do not hear back within one business day from your hospital system please contact your local hospital system or health department directly.

Name

This field is for validation purposes and should be left unchanged.

SmartDocMD Coronavirus/COVID-19 Risk Assessment Tool

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