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Delta Medical Digital Intake
Patient check-in
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DEMO, MARTHA
DOB 01/14/1938 • Dr. Ekadi
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Information
Confirm your details
2
Visit
About your visit
3
AI Notice
Important information
4
Review & Sign
Review and sign
Please confirm your information
Choose an answer for both address and phone. Your choice will stay highlighted.
Please confirm or correct BOTH your mailing address and your primary phone number before continuing.
Mailing Address
123 Main Street Burleson, TX 76028
Phone Number
(817) 555-1234 Mobile
Email Address
About your visit
Please review each section. Every button stays highlighted after you choose it.
Emergency Contact
Insurance REQUIRED
Please confirm whether this is still your current insurance.
Fastest option: take 2 clear pictures of your new insurance card. First the FRONT, then the BACK. We will use the card itself to update your chart so you do not have to type the numbers.
1. FRONT of card
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2. BACK of card
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Pharmacy
Please confirm the pharmacy we have on file.
No pharmacy is currently available from your chart.
Your Medications
If everything is correct and you do not need refills, you do not need to tap anything. Only tap a medicine if you need a refill or no longer take it.
Lisinopril 20 mg tablet
Why are you no longer taking this medicine?
Metformin 500 mg tablet
Why are you no longer taking this medicine?
Atorvastatin 20 mg tablet
Why are you no longer taking this medicine?
Patient History Update
Every YES answer opens a box immediately so you can tell us more.
Wellness Screening
In the past 6 months, have you had problems with urine leakage?
Do you need help managing urine leakage?
How is your physical health?
Does your physical health limit your daily activities?
How often have you felt down, depressed or hopeless?
How often have you felt calm and peaceful?
Have you fallen in the past 12 months?
Are you worried about falling?
Do you use a cane or walker?
Days per week of physical activity?
Do you want help being more active?
Heart Failure Symptom Screen
For patients age 60 and older. We ask these questions about every 6 months.
Do you ever get short of breath while exerting yourself or performing normal daily activities?
Have you noticed a change in your ability to exercise or exert yourself due to shortness of breath or breathlessness?
Have you been reducing your level of physical activity because it feels more difficult to exert yourself?
Vaccinations
Please check the vaccines you know you have already had. It is okay if you do not remember.
Staff will compare this with your eCW immunization record. You do not need to remember exact dates.
Forms for This Visit
Complete each assigned form below. Only one form will be shown at a time.
PHQ-9 Depression Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Please answer all 9 questions.
GAD-7 Anxiety Questionnaire
Over the last 2 weeks, how often have you been bothered by the following problems?
Please answer each question based on how you have felt and conducted yourself over the past 6 months.
Please answer all 18 questions.
Contact & Information Sharing Preferences
Tell us how Delta Medical may contact you and who, if anyone, may receive information about your care.
1. How may we contact you? Select all that are okay.
If any information shown here is incorrect, update it in the Information section of this intake.
2. If we reach voicemail, what may we leave?
Delta Medical may leave information about my care.
Please leave only Delta Medical's name and callback number.
3. Written communication
4. Who may we discuss my medical information with?
Person 1
Person 2
Person 3
Your signature at the end of Digital Intake will also sign this Contact & Information Sharing Preferences form.
Authorization to Use or Share Protected Health Information (PHI)
This authorization is kept in your chart for use when Delta Medical needs to request records. The outside provider or organization is intentionally left blank and may be completed by Delta Medical when the authorization is used.
Outside provider / organization releasing the records
____________________________________________
Intentionally left blank for future use by Delta Medical.
What may Delta Medical request?
Delta Medical may request medical information needed for your care, including office notes, hospital records, test results, imaging, laboratory/pathology reports, and medication records.
Why may Delta Medical request this information?
These records may be requested to help Delta Medical provide, coordinate, and document your medical care.
3. Authorization terms
I authorize the use or disclosure of my PHI as described above, for the purpose(s) listed only.
I may revoke this authorization at any time in writing. Revocation will not affect information already used or disclosed.
I have the right to receive a copy of this authorization.
Unless this authorization is for payment of a claim, signing it will not affect my eligibility for benefits, treatment, enrollment, or payment of claims.
My records may reference communicable or non-communicable conditions, including hepatitis, syphilis, gonorrhea, HIV/AIDS, psychological/psychiatric conditions, or substance use.
I cannot restrict information that has already been shared under this authorization.
Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected.
4. Expiration and representative information
Unless revoked or otherwise indicated, this authorization expires one year from the date you sign it.
Patient / Legal Representative Signature
Signature not yet entered
This authorization expires one year from the date signed unless revoked earlier in writing.
Annual Wellness Checkup
Your once-a-year detailed review of health, independence, safety, habits and daily function.
Not completed yet.
Controlled Substances Treatment Agreement
Please read this agreement carefully. It explains how we will work together to use controlled medicines as safely as possible.
1. Using my medication safely
I will take my controlled medication only as prescribed and will not change the dose or how I take it without first discussing it with my provider.
I will keep my medication in a safe and secure place, away from children and other people.
I will never share, sell, or give my controlled medication to anyone else.
I will tell Delta Medical about other prescription medicines, controlled substances, alcohol, marijuana/cannabis, or other drugs that I use.
I will tell other healthcare professionals caring for me that I receive controlled medication.
I will avoid driving, operating machinery, or other hazardous activities if my medication makes me sleepy, dizzy, confused, or otherwise impaired.
2. Working with one prescribing team
My controlled-substance prescriptions will ordinarily be managed through Delta Medical and one designated pharmacy.
I will tell Delta Medical if another healthcare professional prescribes or recommends a controlled substance for me.
I will not seek additional controlled-substance prescriptions from another clinic or emergency department without informing Delta Medical.
Emergency treatment, surgery, hospitalization, or other circumstances may require another healthcare professional to prescribe medication. I will tell Delta Medical about these prescriptions.
3. Appointments and refills
I must keep required follow-up appointments so my provider can determine whether treatment continues to be safe and helpful.
Controlled-substance prescriptions generally will not be replaced early because medication was lost, stolen, damaged, or used sooner than prescribed.
I should request routine refills at least 4 business days in advance.
Changes to controlled-substance treatment are generally handled during scheduled appointments rather than through after-hours, weekend, or holiday requests.
4. Monitoring for safe treatment
Delta Medical may monitor my controlled-substance treatment to help keep me safe. This may include reviewing the prescription monitoring program (PMP), relevant records or prescriptions from other healthcare professionals or pharmacies, requesting urine or other drug testing when clinically appropriate, and discussing unexpected medication or test results with me.
I agree to participate in reasonable monitoring requested by my provider.
5. Treatment goals and ongoing review
The goal of treatment is not only to reduce symptoms, but also to maintain or improve my ability to function and my quality of life.
Controlled medication may be only one part of my treatment. Other treatments may be recommended when appropriate.
My provider and I will periodically review whether the medication is helping and whether its benefits continue to outweigh its risks.
If treatment is no longer helping enough, causes unacceptable side effects or risk, or cannot be used safely, my treatment plan may need to change, including reducing or discontinuing a controlled medication when clinically appropriate.
6. Important safety information
If I am prescribed an opioid: I understand that opioids can slow breathing and cause overdose. The risk may be greater when opioids are combined with alcohol, benzodiazepines, sleep medicines, or other medications or substances that cause sedation. My provider may recommend or prescribe naloxone, a medication that can reverse an opioid overdose.
Pregnancy and breastfeeding: I will tell my provider promptly if I am pregnant, planning pregnancy, or breastfeeding so that the benefits and risks of my medication can be reviewed.
My Agreement
I understand that failure to use controlled substances safely or to follow the treatment plan may require my provider to reconsider whether continued controlled-substance prescribing is appropriate. Changes in treatment will be based on my individual clinical circumstances and safety.
Signature not yet entered
This agreement remains in effect while Delta Medical is prescribing controlled substances unless it is replaced or discontinued. Delta Medical may ask you to review and sign an updated agreement periodically.
AI-Assisted Technology Notice
Documentation: AI may help prepare notes from your visit.
Telephone assistance: AI-assisted systems may help route calls, scheduling, or patient requests.
Your clinician remains responsible: AI does not replace your healthcare provider's professional judgment.
Privacy: Protected health information remains subject to applicable privacy and security requirements.
Please click the button below to continue.
Review & Sign
Please review the important information below before signing.
Information
Address and phone reviewed.
Insurance & Pharmacy
Insurance and pharmacy reviewed.
Medications
Medication list reviewed.
Recent Health Updates
Recent history reviewed.
By signing, you confirm that:
The information and corrections you provided are accurate to the best of your knowledge.
You reviewed your medications and prescription needs.
You provided your recent health updates.
You received the AI-assisted technology notice.
Financial Responsibility & Authorization
I attest that the above information is a true and accurate representation of my demographic information. I understand that if my insurance company fails to pay Delta Medical for services rendered because of inaccurate information, I will be responsible for payment for services rendered. I understand a fee is payable in advance for completion of all forms and copying of medical records.
I hereby authorize Kofo Ekadi, MD and Delta Medical PA to furnish information to insurance carriers and other physicians and hospitals concerning my illness and treatments and I hereby assign to the physician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance.
If my charges are more than the benefits paid by the insurance company (subject to our agreement with your insurance company) I/WE agree to pay for the difference unless other arrangements are made with the office. You are responsible for co-pays, co-insurance/cost share, deductibles and other charges your insurance company (if insured) designates as your responsibility.
I request that payment of authorized Medigap benefits be made either to me or on my behalf to Kofo Ekadi, MD or Delta Medical PA for any services furnished to me by any physician from the practice. I understand that Delta Medical PA is not responsible for filing any secondary insurance and any balance after my primary insurance pays is my responsibility. I agree and allow the clinical staff of Delta Medical PA to view my medication history from external sources. I have read and understood the above.
Please review the statement above, then sign below.
Signature not yet entered
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STAFF PREP
Appointment date → patient details → forms needed → medication PDF only when needed
Shared data refreshes only when you click REFRESH SHARED DATA
Patient schedules
WORK BY APPOINTMENT DATE
Use the same schedule CSV already generated for DMC Encounter Docs. Different staff members may work on different appointment dates at the same time.
No schedule loaded for this date yet.
OCCASIONAL — NOT REQUIRED EACH DAY
Optional master-data refresh for pharmacy, emergency contact, email and insurance. One bulk report can enrich many patients.
Select a patient
After the schedule loads, choose a patient to prepare forms and medications.
Simple workflow: choose any forms needed for this visit → prepare medications only if the saved list needs updating → open the patient intake. Use Quick Forms only for an on-demand form during the encounter.
ON-DEMAND DURING AN ENCOUNTER
Quick Forms
Launch a single form without sending the patient through Digital Intake.
Patient forms can be launched here on demand. Mini-Cog and STOP-Bang stay on the staff/provider side. Contact Preferences and PHI Authorization remain encounter-only forms.
Forms for this encounterStaff chooses only when needed
MINI-COG REQUIRED — STAFF ADMINISTRATION. Administer Mini-Cog directly with the patient using the usual office workflow. It will NOT appear in the patient's Digital Intake.
Simple rule: check the form only when this patient needs it. A checked form can be unchecked or removed if selected by mistake.
When Annual Wellness Checkup is selected, it replaces the shorter routine Wellness Screening for that encounter.
Encounter outputs
After submission: Patient Intake Form is the durable chart record; Registration Update and Scribe Summary are staff work products.
PATIENT TAKE-HOME DOCUMENT
After the provider completes the superbill, use it to prepare the patient's simple action sheet.
Completion tracking
Use these buttons to show the team what has already been completed for this intake.
Provider review
Use this only when something in the intake needs the provider's attention. Click again to remove the flag.
Medication listPer patient, only when needed
Use the patient's Current Medications PDF only when no saved list exists or the saved list needs refreshing.
Use this only after confirming the patient has no current medications in eCW.
Review medication list
Nothing is saved until approved. Compare against the original PDF or pasted source; duplicates and differing strengths require human reconciliation.
Saved medication list
Encounter Flow Board
One row per patient for the selected appointment date. NEEDS ACTION shows exactly what staff still must do.
Load or open a schedule date to populate the board.
Add Walk-In / Patient
Add one patient without uploading a schedule.
Epworth Sleepiness Scale
DELTA MEDICAL, P.A.
Kofo Ekadi, M.D., FACP
Sarah Mitchell, FNP-BC
Epworth Sleepiness Scale
How likely are you to nod off or fall asleep in the following situations, in contrast to feeling just tired?
This refers to your usual way of life in recent times. Even if you haven't done some of these things recently, try to work out how they would have affected you. It is important that you answer each question as best you can.
Choose one answer for each situation.
Please answer all 8 situations before submitting.
✓ Epworth completed. Please return the tablet to the staff member.
Quick Form
Please answer every item before submitting.
Mini-Cog — Staff Administration
STAFF TASK ONLY. Administer the Mini-Cog directly with the patient using the usual office workflow. It will not appear in the patient Quick Form screen.
Annual Wellness Checkup
Please choose an answer before continuing.
Controlled Substances Treatment Agreement
Signature not yet entered
STOP-Bang Questionnaire — Provider / Staff
CLINICAL STAFF FORM. Complete during the encounter. This screen is not intended for patient self-administration.
Please answer all 8 items before submitting.
Encounter Output
Staff sign-in
Sign in with the Google account the office approved for you.
Set up your staff authenticator
On your own phone, open Google Authenticator or Microsoft Authenticator and choose Add account. Scan the QR code, or enter the setup key manually.
Keep this key private. It will disappear when you close this window.