Diabetes Call Center Intake Form First Name * Last Name * Phone * Email Address Reasons(s) for Call * Appointment Request General Questions Insurance Question Lab Results Medication Side Effects Need Password Reset Not Feeling Well Pay Bill/Billing or Co-Pay Questions Prescription Renewal Records Request Speak with Doctor OTHER (add details to notes) ESCALATION (add details to notes) Patient Type * BlankEstablished PatientNew Patient Do you have health insurance? * BlankYesNo (ONLY ASK NEW PATIENTS.) If yes, who is your health insurance provider? (ONLY ASK NEW PATIENTS.) Do you have a primary care physician? * BlankYesNo (ONLY ASK NEW PATIENTS.) If yes, who is your primary care provider? (ONLY ASK NEW PATIENTS.) Notes How did you hear about us? BlankBeacon - DelandBillboardBing SearchDaytona Beach News JournalDirect MailDoctorFriendGoogle SearchHometown NewsInstagramOrlando SentinelOtherSocial MediaTelevision NetworkVotran Bus (ONLY ASK NEW PATIENTS.)
