SAMPLE FORM - MEDICAL OFFICE

MEDICAL OFFICE

CALL & MESSAGE LOG
Caller Name: *

First NameLast Name
Initials*
initials for intervals
Caller Phone

Area CodePhone Number
Current Patient?

YesNo
Type of Call:*

IncomingOutgoing (call we placed)
Sometimes the caller and patient are different. If that's the case please enter the patient name below, or put 'same' in the last name box.
Patient Name:

First NameLast Name
Patient Phone:

Area CodePhone Number
If patient had a procedure and is now experiencing issues because of that procedure, check 'procedure issues'. If a patient is asking about scheduling a procedure check 'procedure scheduling'.
Reason for Call:*
If Current Patient DOB

MonthDayYear
Appointment Set:

MonthDayYear
DateHourMinutesAM/PM Option
Message / Notes:*
Team Member Name: *
Logged:

MonthDayYearHourMinutesAM/PM Option
TIME TO COMPLETE FORM
Should be Empty: