Hidden
Location
(Required)
Facility Information
Organization Type
(Required)
Select One
AFC (Adult Foster Care)
HFA (Home for Aged)
Jail
LHD (Local Health Dept)
MDOC (Mi. Dept of Corrections)
Migrant Workers
Neighborhood Testing
Public Facing (i.e. Drive Thru or Pop Up)
Public Venue
School
Shelter
SNF (Skilled Nursing Facility)
Training
OTHER - STATE AGENCY (i.e. DMVA or Psych. Hospital)
OTHER - NON STATE AGENCY
Organization ID (i.e. District Code):
Building ID (i.e. School Entity):
Facility Name
(Required)
Facility Street Address
(Required)
Facility City
(Required)
Zip Code: 5 digit (XXXXX)Mandatory
(Required)
Phone: (XXX-XXX-XXXX)
(Required)
Description:
Doctor's/responsible email
(Required)
How do you want to host from your sub-domain?
(Required)
Yes
No
Note: If you choose "Yes" Additional information will be required. If you choose "No" we will host from lab.medmozo/your-org-name. "If you are not sure, choose 'No' "
Enter Your Sub-domain:
(Required)
Your patient support system information
Email for patients’ inquiries
Phone for patients’ inquiries
Hidden
Patient information
Any of this information you need
Hidden
Basic patient information
Patient Name
Patient Phone Number
Patient Email
Patient Date of Birth
Patient Gender
Patient Address
Select All
Hidden
Insurance Information
Hidden
Do you want to ask the patient about his insurance?
Yes
No
Hidden
Please specify the information and questions you want the patient to enter
Do you have insurance?
Insurance Plan Name
ID Number
Group Number
Insured Details(Relationship , Insurance card(s) front/back image)
Add secondary insurance(with same details)
Select All
Hidden
Add additional questions
Add
Remove
Hidden
Do you want to add notes to the questions?
Hidden
Screening Questionnaire
Hidden
Do you want to ask the patient Screening Questionnaire?
Yes
No
Hidden
Please specify the information and questions you want the patient to enter
why are you being seen?
Is this your first Covid PCR test?
Are you having any of the following symptoms?( Fever- Chills - Headache - Body aches - Sore throat - Cough - Difficulty breathing - Nasal congestion - Diarrhea - Vomiting - Recent travel - Loss of taste or smell )
Have you been hospitalized in the last 14 days?
Do you work in Healthcare?
Are you immunocompromised?
Do you have any underlying medical condition(s)?
Have you had any possible or known EXPOSURE to COVID-19 ?
Have you ever tested to POSITIVE for COVID-19?
Have you received a COVID-19 vaccination?
Select All
Hidden
Add additional questions
Add
Remove
Email & SMS
Do you want to send an email to the patient?
Yes
No
Email Subject
From
If you need send email from your domain
cc
Message
Dear {Patient Name }, Thank you, please find attached your test result. Note: The file is encrypted with a password, use your date of birth in the format (MM/DD/YYYY) as your password. For any questions or modifications, please contact with us @ example@example.com. Regards
Note: If you would like to send the confirmation email from your domain, additional information would be required.
Do you want to send a SMS to the patient?
Yes
No
SMS message
Dear {Patient Name} The results are ready. Your accession number is {******} Visit https://example.com/ to get the results.
Every 150 characters is a message.
Do you want to send a review SMS to the patient?
Yes
No
Review message
Thanks for choosing {Your organization name}. Please take a few seconds and review us at https://example.com The biggest thank you for our team's effort is a 5-star google review.
Every 150 characters is a message. (Preferably include your location in Google Maps)
Any special request?
Add
Remove
PDF Please upload your current result format
Accepted file types: pdf, docx, Max. file size: 3 MB.
Please upload your current patient registration form
Accepted file types: pdf, docx, Max. file size: 3 MB.
Signature
Δ
