Practice Mini Intake Form
En Español
In English
Felipa: Hi I'm Felipa. The doctor wanted me to follow up with you on a couple of things before you leave. Before we do that, I just need to verify some information. It won't take a lot of time.
So I have that you live at 126 Spring Mountain Rd in Las Vegas 89146 and your home phone number is 702-785-4432.
Fatima: No, I'm now living with my sister at 897 Sewell Street. The zip code is the same. Also my phone number has changed: 702-652-9887. It's my cell phone.
Felipa: OK, let me just confirm: 702-652-9987.
Fatima: Yes.
Felipa: The doctor wanted me to schedule you for a mammogram. Guadalupe Center is close to where you live. Would that work for you?
Fatima: It's not that far but I don't have a car and the buses don't come very often.
Felipa: I can give you a voucher for a cab to get you there and back. Would that work?
Fatima: That would be very helpful. Thank you.
Felipa: Right now there's a month wait but I'd still like to get it scheduled. What would be the best day and time for you to go?
Fatima: I work evenings on Tuesday, Thursday, and Friday so during the day on one of those days would be best.
Felipa: Just in case there is not a Spanish speaker available on that day, I'm going to call Interpreter Services to make sure there is someone there who can interpret for you. Does that sound good?
Fatima: Yes
Felipa: Do you have any other questions?
Fatima: No.
Felipa: OK, I'll try to call you later today once I have it scheduled. I don't work tomorrow so, if I don't get back to you today, another Community Health Worker named Susana will call you tomorrow.