Appointment reminders & communicating healthcare alternatives
We may need to contact you to provide appointment reminders, rescheduling or treatment alternatives.
How my we contact you?
Home phone: Yes/No
Cell phone: Yes/No
Email: Yes/No
Work phone: Yes/No
May we leave a message on your voice mail or answering machine?
On your Home phone: Yes/No
On your Cell phone: Yes/No
By Email: Yes/No
Work phone: Yes/No
May we leave a message with your employer or family member?
Employer: Yes/No
Family member: Yes/No
Signature of patient: Date: