Fillable Printable Sample Telephone Message Form
Fillable Printable Sample Telephone Message Form
Sample Telephone Message Form
Telephone Triage/Message Form [Sample]
Message taken by:
Date Time Patient Name
Problem/Patient Complaint:
Current Medications
Caller’s name if not patient:
Relationship to patient:
Other Medical Problems
Allergies
Phone #
Patient’s A
g
e Weight
Work Phone #
Pregnant? Primary Care Physician
Cell Phone #
From _____am/pm To _____ am/pm
Patient can be reached
at home on cell at work
Problem/Patient Complaint (cont. if necessary):
Medication refill (circle) Medication
Pharmacy Name Phone #
Follow up:
ER referral
Appointment made for ________________ at _________
Physician to call. Physician called on ______________ at _________.
Pharmacy called. Refill ready at __________.
Home health referral
Specialist referral
Communication with patient:
Treatment Plan:
Clinical Advice Given to Patient:
Patient Verbalizes Understanding of Treatment Plan and/or Clinical Advise Given.
Comment:
Patient Understands to Call Back if Symptoms Worsen or to Call the ER if the Office Is Closed.
Comment:
Call returned by
Date/Time Provider consulted
Yes No
Provider signature:
Date/Time
Medical Mutual's "Practice Tips" are offered as reference information only and are not
intended to establish practice standards or serve as legal advice. MMIC recommends you
obtain a legal opinion from a qualified attorney for any specific application to your practice.
