On-Site Activation

Action	Labels	Appointment ID	Confirmation No	Patient	Payment	Appointment
Action	Labels	Appointment ID	Confirmation No	Patient	Payment	Appointment
Profile Merge Pt Cancel Appt	New PT Covid	APTID-1-1	X34G56	PTID-1-2 Shakir Ansari 11/29/1982	Authorize.net 254125874584 $45.00	OC FAIR GROUND 10/25/2020 8:00 PM - 8:30 PM
Profile Merge Pt Cancel Appt	Est. PT Covid	APTID-1-2	TR45H4	PTID-1-1 Saimun Hasan 11/29/1998	P-Verify 22523366523 Valid	OC FAIR GROUND 10/25/2020 8:00 PM - 8:30 PM

Your Information

First Name

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Address

Street

City

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Contact Information

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SMS Notification

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Primary Insurance

Primary Insurance Provider

Primary Insurance Member ID

Primary Pverify Status

Primary Insurance Group Number

Primary Relationship to this insured

Primary Insurance Int

Secondary Insurance

Secondary Insurance Provider

Secondary Insurance Member ID

Secondary Pverify Status

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Secondary Relationship to this insured

Secondary Insurance Int

Identification

Identification Type*

Identification Number

Identification Upload

Identification Type*

Identification Number

Identification Upload

Identification Type*

Identification Number

Identification Upload

Appt Date	DOS	Check In Status	Soap Status	Result Status	Follow up Status	Billing Status
Appt Date	DOS	Check In Status	Soap Status	Result Status	Follow up Status	Billing Status
10/22/2020	10/23/2020	Signed Off	Physical Exam	Waiting Notification	Follow Up Needed	Ready to Bill
10/22/2020	10/23/2020	Signed Off	Physical Exam	Waiting Notification	Follow Up Needed	Ready to Bill

Appointment Date	DOS	Collection Date	Payment Type	Amount
Appointment Date	DOS	Collection Date	Payment Type	Amount
Appointment Date	DOS	Collection Date	Payment Type	Amount

PTID	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID-1-1	Shakir	Ansari	10/10/1990	9173595860	Street	City	State	Zip

PTID	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID	First Name	Last Name	DOB	phone	street	City	State	Zip
PTID-1-1	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID-1-2	First Name	Last Name	DOB	Phone	Street	City	State	Zip

Choose Location

Location ID	Location Name	Street	City	State	Zip
Location ID	Location Name	Street	City	State	Zip
LID-1-1	OC FAIR GROUND	7037 Rose Ave	Orlando	FL	32810
LID-1-2	OC FAIR GROUND	7037 Rose Ave	Orlando	FL	32810

Choose Product

Product Name	Product ID	Price	Payment Type
Product Name	Product ID	Price	Payment Type
Product 01	PID-1-1	$25	Credit Card
Product 02	PID-1-2	$50	Cash

Choose Date

Date	Available Slots
Date	Available Slots
06/10/21	70
07/10/21	70
08/10/21	70

Choose Time

Time	Available Slots
Time	Available Slots
04:00 PM - 05:00 PM	5
05:00 PM - 06:00 PM	20
06:00 PM - 07:00 PM	15

PTID	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID	First Name	Last Name	DOB	phone	street	City	State	Zip
PTID-1-1	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID-1-2	First Name	Last Name	DOB	Phone	Street	City	State	Zip

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This patient is a minor and selected the Minor - No ID option