GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. ✦ Assemble necessary appointment
scheduling equipment.
2. ✶ Obtain the patient’s full legal
name and correct spelling, birth
date, full address, telephone
contacts (home, oce, cell), and
e-mail address.
3. ✦ Record the patient’s chief
complaint and symptoms.
4. ✶ Request the name of the patient’s
insurance carrier and policy
number.
5. ✦ Ask how the patient was referred
to the medical oce (physician
referral, friend, colleague,
insurance company, etc.).
6. ✦ Ask if the patient has a preference
for morning or afternoon
appointments.
7. ✦ Attempt to accommodate the new
patient’s request for a preferred
appointment time.
8. ✦ Confirm the day, date, and time
of the appointment and have
the new patient repeat the
information for verification and
mutual understanding.
9. ✦ Advise the patient of any need
to arrive early, before the ocial
appointment time, to complete
paperwork, such as the patient
history form and HIPAA consent.
10. ✦ Provide the new patient with
directions to the oce.
Name: ________________________________________
Date: _________________________________________
POINT VALUE
✦ = 3–6 points
✶ = 7–9 points
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