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Patient Screening Form - CareNow 2026

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The document is a comprehensive patient screening and consent form used by CareNow Urgent Care. It includes sections for tuberculosis symptoms, exposure to infectious diseases, patient demographics, occupational medicine details, HIPAA acknowledgment, and authorization for the disclosure of protected health information. The form aims to ensure patient safety, collect necessary medical history, and obtain consent for treatment and information sharing.

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Click ‘Get Form’ to open the Patient Screening Form - CareNow in the editor.
Begin by answering the initial screening questions regarding symptoms of tuberculosis and other conditions. Select 'YES' or 'NO' for each question.
In the section for travel history, list any countries visited outside the United States in the past three weeks.
Fill in your personal information, including your name, date of birth, and contact details. Ensure accuracy for effective communication.
Sign and date the form where indicated, confirming that all information provided is correct.
If applicable, complete any additional sections related to occupational medicine demographics and injury details.
Review all entries for completeness before submitting the form through our platform.

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