.PUBLIC PORTAL
Sign in
.PUBLIC PORTAL - Add Record
 
For which table?
Patient Inquiries
Outpatient-Satisfaction Survey
Nutrition -Satisfaction Survey
Surgery-Satisfaction Survey
Suggestions
Vaccine Registry-COVID
Vaccine Registry-Influenza
Patient's Relatives
Follow Up
Patient Forms
Suggestion-Updates
Cat
Images
Guide
Website Communication
Provider Sync
Vaccine Location
Cancel

Open
Open in New Window

We are updating our Terms of Service. See our blog post highlighting the changes. By continuing to use the Quickbase Service, the new Terms of Service will become effective on the renewal date for each account that you manage. If you do not accept the changes, please notify us thirty days in advance of your renewal date.
Quickbase will send a report of the events currently displayed on your calendar.
New apps will be added to your account close
close
Create your own free Quickbase app
Quickbase Exchange has hundreds of free apps for any business process.
It's simple to get started and you don't need to be technical to do it.
  • Project Management
  • Customer Support
  • Sales & CRM
  • Marketing
  • Team Management
  • Human Resources
  • Information Technology
  • Industry-specific solutions
Find an app in Quickbase Exchange
close
We need to check with your admin first...
We know you're eager to create your first app-but your account settings don't let you create apps yet. We've asked your account admin to allow it, and you'll get an email from us when you can.
Prefer a more hands-on solution? Can't wait? Try a 30-day free trial, and get started creating apps immediately.
Build a new app from scratch Import a spreadsheet to create a new app
Start a trial
Quickbase is a web-site that lets you select, customize, and share online workgroup applications. The application you are using right now is powered by Quickbase.

Chances are that your organization has purchased the Quickbase service, in which case you might be able to build and deploy your own web application for little or no additional cost.

You have permission to create your own web applications.

To find out more about Quickbase, visit our web site.

Terms of Service



For which table?

Patient Inquiries Outpatient-Satisfaction Survey Nutrition -Satisfaction Survey Surgery-Satisfaction Survey Suggestions Vaccine Registry-COVID Vaccine Registry-Influenza Patient's Relatives Follow Up Patient Forms Suggestion-Updates Cat Images Guide Website Communication Provider Sync Vaccine Location
  • From scratch
    Design your own table
Patient Inquiries

Add Record

Save & close Cancel
Create a new Quickbase user by entering his/her email address, first name, and last name below:

Email address:
First Name:
Last Name:
  • Save & close
  • Save & new
  • Save & close
  • Save & new
Prev | Next

UNITED MEDICAL PATIENT INQUIRY FORM
United Medical, LLC
 *
 *
Please either start typing your doctor's name, or name of the practice:
 *
 * ext.
BILLING DISPUTE/QUESTION/OTHER
INSURANCE UPDATE
Online Payment
Recurring Payments Agreement
Dear Patient:

With your authorization, we will regularly process automatic deductions from your credit/debit card until your balance is paid off in full. A receipt will be mailed to you each time and the charge will appear on your credit/debit card statement. Since these will be scheduled transactions, we will not notify you prior to each scheduled deduction. If the amount you owe is less than the scheduled transaction, we will process payment for the amount you owe.
 
I certify that I am an authorized user of the credit/debit card (For your security, we will have one of our representative call you to obtain the Credit/Debit Card information). I understand that if the scheduled day of deduction falls on a holiday or weekend, deduction will be processed on the next business day. I understand that this authorization will remain in effect until the balance is paid in full and that I may terminate this authorization by providing the office with a written notice at least 15 business days prior to the next scheduled deduction. I understand that it is my responsibility to notify My provider office of any changes in my account information.  I agree not to dispute the scheduled payments with my credit/debit card company for transactions described herein. I understand that Provider's office will not be responsible for any fees related to insufficient funds. I have reviewed and understand the content of this form in its entirety and my signature below serves as my authorization. I understand and agree that my electronic signature for this form is as valid as my written signature.
Missing Cash Payment
Missing Credit Card Payment
Missing Check Payment
Proof of Payment
 
Payment Plan Arrangement
 
If you would like to set up payment plan terms you must comply with the following guidelines.

1.    First payment must be submitted with this form within 10 days of this letter's date for review of this account for a payment plan. If no  payment is received  balances in full may be transferred to a collection agency.
2.    Payments must be received every 30 days.
3.    Payment plans must not exceed 12 months.
4.    Payments should be of equal amounts and cannot be less than 20% of the balance total.
5.    All payment plans must be approved and acknowledged and replied with a letter and coupons for acceptance.

 Please make certain you complete the contact information fields
Chart Request Details






Consent to release your medical records must be signed and returned prior to us sending your medical records.

If possible, please print the attached form and fax it to 866-334-5338.  If you are unable to fax the form, please bring it with you to your appointment.
Please Click Here to Download Consent Form
 
Show fields from Show fields from Show fields from a related table
Save & close Cancel
Quickbase Performance Bar
Browser
Unknown
Quickbase Response Time
0.03 sec
Unknown
Network
[Run Network Test]
Unknown
Performance statistics for .PUBLIC PORTAL

The information in this email was generated by the Quickbase Performance Bar and can help diagnose issues I'm experiencing with my Quickbase application. It provides information about network and server performance during the most recent Quickbase action I initiated.

You can read this Knowledgebase article to learn more about the types of actions that can affect Quickbase performance.

ID: eeaf556e-626a-9f8f-bed4-ec99f99579e8
Application/Table: Patient Inquiries
Action: gennewrecord
Parameters:
User:
Request Time (in UTC): 2025-05-12 18:36:49 (UTC)
Quickbase Response Time: 0.03 sec
Browser information:
Network traffic speed:

 
 
 
 
 
 
Don't show me this message again

 

Can I annotate fields to indicate their intended use?

Yes. You can provide "Help" to your users for any field:

1. On any page in your application, click "Customize" then "Fields". If it is a multi-table application, select the table.

2. Click the "Edit" button next to the field for which you want to add an annotation.

3. In the "Help" text input box, enter text that will assist your users, and click "Save".

Your text will appear when the user hovers over or clicks on the question mark icon next to that field on the Add Record and Edit Record pages.
 
foo

We're glad you're interested in doing more with Quickbase!

Now we need to make you official before you share apps or manage your account.

Verifying your email lets you share Quickbase with others in your company.

Your work email
Your company
Client Performance Report
Network latency: ()
The time taken for page load once the page is received from the server:()
The total process of navigation and page load: ()

From inline js at page top..
        .. to the time until docready:( s)
        .. to the time until window load begins: ( s)
        .. to the time until window load ends: ( s)
  • User profileProfile
  • Sign up linkSign up now
  • Manage realmManage
  • LogoutSign out
  • This app
  • .PUBLIC PORTAL
  • Your role is Internet
  • Switch accounts
  • {{firstServiceAccount.FirstName}} {{firstServiceAccount.LastName}} (Service)
    {{firstServiceAccount.Email}}
  • {{secondServiceAccount.FirstName}} {{secondServiceAccount.LastName}} (Service)
    {{secondServiceAccount.Email}}
  • More accounts
    • {{serviceAccount.FirstName}} {{serviceAccount.LastName}} (Service)
      {{serviceAccount.Email}}
You've made changes to this Record. Do you want to save these changes before going to the next screen?
Report Name *
Description
Reports and Charts Panel
Each table has a panel listing its reports and charts, organized in groups.
Please wait while your new report is saved...
Print the report as a table
Print one Record per page ( total)
Using the form:
Print as much of the timeline as fits on a single page
Print the timeline over multiple letter-size pages in landscape orientation
  • New subscription...
  • Print
  • Search & replace in this report...
  • Save as a spreadsheet
  • Clear New and Updated flags
  • Sorting & grouping...
  • View as a calendar
  • View as a timeline
  • Change the owner of these records...
  • Delete all records in this report
  • Show the expanded URL for this report
  • Report
  • Group up Group down
    Hide this column Add a column...
    New table based on this column...
    Column properties... Field properties...
    grouping by
    Field label
    Column heading override
    Justification
    What does auto mean?
      Multiple values found.   more...
    Fields in:

    Fields to Extract:

    Name for the new table:
    Items in the new table are called:

    When you bring additional fields into a conversion, Quickbase often finds inconsistencies. For example, say you're converting your Companies column into its own table. One company, Acme Corporation, has offices in New York, Dallas and Portland. So, when you add the City column to the conversion, Quickbase finds three different locations for Acme. A single value in the column you're converting can only match one value in any additional field. Quickbase needs you to clean up the extra cities before it can create your new table. To do so, you have one of two choices:

    • If you want to create three separate Acme records (Acme-New York, Acme-Dallas and Acme-Portland) click the Conform link at the top of the column.
    • If the dissimilar entries are mistakes (say Acme only has one office in New York and the other locations are data-entry errors) go back into your table and correct the inconsistencies—in this case, changing all locations to New York. Then try the conversion again.

    Read more about converting a column into a table.


    Cut
    Copy
    Paste
    Paste Special

    Fill Down
    Reset to Original Values

    Insert Blank Rows
    x
    x

    Undo

    Edit this Field's Properties...
    x
    x

    Editing Conflict
    you changed ' '
    from:
    to:
      changed ' '
    from:
    to:

    To Paste

    To paste clipboard data that comes from another program right-click on the text area below, select Paste, then click OK.
    Unable to Save Changes
    While you were editing these records, someone else was also editing some of the same records and made changes that conflict with some of your changes.
    Unable to Save Changes
    You are no longer signed in to Quickbase.
    Either your session expired or you signed out in another browser window.
    Please sign in below and then click the Save Changes button again.
    Sign in failed. Please try again.
    Email address (or user name):
    Password:
     
  • Expand this section to show all related x
  • Collapse this section and make it scrollable
  • Clear "New" and "Updated" Flags for all x