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Office Hours

Monday-Friday: 9am to 6pm

Saturday: 9am to 4pm

Sunday: Closed

Clynix BioMed Testing, Telemedicine & Rapid Care

Address:

105 Vulcan Road Suite 110

Homewood, Al. 35209

Email: support@clynixhealth.com

Phone: (205) 202-0898

Clynix BioMed Testing & Telemedicine

General Patient Intake Form

Patient Demographics

First name

Last name

Birthday

Month

Day

Year

Sex At Birth:

Phone

Email

Home Address (Required For Telemedicine)

Address

Emergency Contact

Name and Phone Number

Telemedicine Location Confirmation

I confirm that I am physically located in the following state at the time of my telemedicine visit:

State:

Preferred Pharmacy

Pharmacy Name:

Pharmacy Address:

Pharmacy Phone:

Insurance & Payment Selection

I will use insurance

I am a self-pay/cash-pay patient

Insurance Carrier

Member ID:

Group #:

Acknowledgement

I certify that the information provided above is accurate and complete to the best of my knowledge.

Patient Signature:

Date:

Privacy Policy (HIPAA)

Notice of Privacy Practices (NPP)

Telemedicine Consent

Controlled Substance Policy

Emergency & Crisis Disclaimer

Terms of Service

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