Medical Appointment Checklist

MEDICAL APPOINTMENT CHECKLIST

WHEREAS

WHEREAS Clinic Name: operates a medical practice that provides evaluation, diagnosis and treatment to patients; and

WHEREAS Patient Name: seeks care and agrees to comply with clinic policies and to provide accurate medical information in connection with the scheduled appointment.

WHEREAS the parties wish to document pre-appointment requirements, pertinent medical history, payment arrangements and mutual acknowledgements to promote safe and timely care.

PATIENT INFORMATION

APPOINTMENT DETAILS

Appointment Date:    Time:    Provider:

New patient visit    Follow-up    Telehealth/virtual visit    Procedure or testing

SCOPE OF SERVICES

Describe the services, examinations and procedures anticipated for the appointment. This scope may include history and physical evaluation, diagnostic testing, counseling and minor procedures as indicated by clinician.

PAYMENT TERMS

Standard fee for this appointment: $

Late payment penalty: . Patient is responsible for all collection costs and reasonable attorney fees if applicable.

TERM AND TERMINATION

This checklist applies to the appointment(s) occurring between Start Date: and End Date: unless earlier terminated in accordance with clinic policy.

Notice required to cancel or reschedule recurring appointments: . Failure to provide timely notice may result in assessed cancellation or no-show fees.

MEDICAL HISTORY CHECKLIST

Please indicate conditions that apply (check all that apply):

Diabetes    Hypertension    Heart disease    Asthma/COPD    Kidney disease    Bleeding disorder    Other (specify below)

PRE-APPOINTMENT INSTRUCTIONS & CHECKLIST

Please confirm the following items prior to or at check-in:

I will bring photo identification    I will bring insurance card(s)    I will bring a complete medication list

Fasting required prior to appointment: Yes    No    If yes, last solid food:

SYMPTOM SCREENING

Have you experienced any of the following within the past 14 days? (check all that apply)

Fever or chills    New or worsening cough    Shortness of breath    Loss of taste or smell    Known exposure to infectious illness

If any boxes checked, patient agrees to notify clinic before arrival and may be rescheduled per clinic policy.

CONFIDENTIALITY

All personal health information provided in connection with this appointment is subject to applicable privacy and confidentiality protections. The clinic will use and disclose information only as necessary to provide medical care, for billing and payment, or as required by law. Patient authorizes use of information for these purposes.

GOVERNING LAW

This checklist and any disputes arising hereunder shall be governed by the laws of the State of without regard to conflict of law principles.

ENTIRE AGREEMENT

This checklist, together with any separate consent or financial responsibility forms executed by the patient, constitutes the entire understanding between the patient and the clinic regarding the listed appointment(s) and supersedes any prior oral or written communications. Any modifications must be in writing and signed by an authorized clinic representative and the patient.

ACKNOWLEDGEMENTS AND CONSENT

By signing below, Patient attests that the information provided in this checklist is true and complete to the best of their knowledge, understands the payment terms and cancellation policy, consents to the scope of services described above, and authorizes the clinic to perform routine and medically necessary care.

Patient Printed Name:    Relationship to patient (if signing for patient):

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