First Name
Last Name
Date of Birth
Office
Maxwell Medical, PC (301 Madison Avenue, 5th fl, New York, NY 10017-8102)
Maxwell Medical Health, PC (16 E 52nd Street, #502, New York, NY 10022)
Maxwell Madison Medical, PC (111 Broadway, #503, New York, NY 10006)
Maxwell Midtown Medical, PC (150 E 58th Street, 14th fl, New York, NY 10158)
Maxwell 21 Medical, PC (54 W 21st Street, #509, New York, NY 10010)
Is the contact information we have on file for you still accurate?
Yes
No
If no, please enter information
Is the insurance we have on file for you still active?
Yes
No
If no, please enter information
Do you have any of these symptoms? Please select all that apply.
Fever greater than 100 degrees
Dry Cough
Shortness of Breath
Sore Throat
Runny Nose
Loss of Sense or Smell
None of the above
Do you live with someone who works as a...?
First Responder
Healthcare Worker
Nursing Home Employee
Essential employee with direct contact with the public while working
Have you been in close contact (within 6 feet) with someone who is diagnosed with COVID-19?
Yes
No
Have you had COVID-19?
Yes
No
Have you been tested for COVID-19?
Yes
No
If yes, please enter information
Date:
Result
Select Result
Positive
Negative
Are you clear of COVID-19 now?
Yes
No
Since which date:
Other Underlying Illnesses:
Travel History
Have you traveled internationally in the last 14 days?
Yes
No
Type of Appointment
In Office
Telehealth
Desired Appointment Date
Desired Appointment Time
Submit
