This contact sheet is available for download in two formats:
PDF - 53 KB
Microsoft Word - 29.2 KB
If possible, pull information from patient's medical record. Confirm correct information with patient. Identify the best time of day or days to reach the patient and other contacts.
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Patient Name: _________________________________________________________ OK to send letter (Y / N) Address City, State ____________________ ZIP Code _____ Email address _________________________________________________________ |
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Preferred spoken language: _____________________________________________ Interpreter needed? (Y/N) ______ Preferred phone number: __ home __ cell phone __ work Home Phone: ( )_______________________ OK to leave message? (Y/N)____ Best time to call: _______________________ Cell Phone: ( ) _ OK to leave message? (Y/N) Best time to call: _______________________ Work Phone: ( ) _ OK to leave message? (Y/N) Best time to call: _______________________ |
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Contacts Name of Contact 1: ____________________________________________________ Relationship: __________________________________________________________ _____________________________________________________________________ |
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Preferred spoken language: _____________________________________________ Interpreter needed? (Y/N) ______ Preferred phone number: __ home __ cell phone __ work Home Phone: ( )_______________________ OK to leave message? (Y/N)____ Best time to call: _______________________ Cell Phone: ( ) _ OK to leave message? (Y/N) Best time to call: _______________________ Work Phone: ( ) _ OK to leave message? (Y/N) Best time to call: _______________________ |
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Contacts Name of Contact 2: ____________________________________________________ Relationship: __________________________________________________________ _____________________________________________________________________ |
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Preferred spoken language: _____________________________________________ Interpreter needed? (Y/N) ______ Preferred phone number: __ home __ cell phone __ work Home Phone: ( )_______________________ OK to leave message? (Y/N)____ Best time to call: _______________________ Cell Phone: ( ) _ OK to leave message? (Y/N) Best time to call: _______________________ Work Phone: ( ) _ OK to leave message? (Y/N) Best time to call: _______________________ |
