Medicare Intake Appointment Sheet

 

 

  • MEDICARE INTAKE APPOINTMENT SHEET

  • PERSONAL INFORMATION

    Here is where you will be documenting information on the individual(s) to be seen
  • Please enter today's date
  • Primary contacts name
  • Date of birth of primary contact mm/dd/yy
  • Spouses name
  • Date of birth of spouse mm/dd/yy
  • Is the primary or contact a current customer?
  • Street address
  • Please document as (area code) 555-5555
  • Please document as (area code) 555-5555
  • QUESTIONANAIRE SECTION

    This is the area you will document answers from specific questions in your scripting
  • If they answered NO to previous question. If they have applied answer N/A
  • Be as descriptive as possible
  • Be as descriptive as possible
  • Be as descriptive as possible
  • MEDICATIONS

    Here we will document the various medications they and/or their spouse is taking. You will be asking for the type of medication, the milligrams and doses per day
  • What is the type of medication taken
  • What is the milligram amount of medication taken
  • What is the dosage per day (# of times taken)
  • What is the type of medication taken
  • What is the milligram amount of medication taken
  • What is the dosage per day (# of times taken)
  • What is the type of medication taken
  • What is the milligram amount of medication taken
  • What is the dosage per day (# of times taken)
  • What is the type of medication taken
  • What is the milligram amount of medication taken
  • What is the dosage per day (# of times taken)
  • What is the type of medication taken
  • What is the milligram amount of medication taken
  • What is the dosage per day (# of times taken)
  • If they have more than 6 medications please list out here, include milligram amount & dosage
  • If they have a doctor they must keep, please indicate their name here
  • If they have a doctor they must keep, please indicate their phone # here
  • If they have a doctor they must keep, please indicate their address here
  • If they have more than 1 doctor they must keep, please list the name of doctor, address & phone # here for all indicated
  • APPOINTMENT INFORMATION

    Enter in details of the appointment in this section
  • Is the appointment AM or PM?
  • Please indicate the type of residence appointment will be at
  • If yes please indicate code or special instructions
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