Contact Information Checklist __[1] Date ___________
“Thank you for calling Dr. ____________ office. This is ____________. How may I help you today?
Patient Name __________________________, Pronounced ________________
New Pt ______, Current Pt _______ Urgent Care ______
“Who may we thank for referring you to our office?” ______________________
Chief Complaint (their words) _____________________________________________
Urgent Care Questions: Discomfort, Tooth, Removable, Periodontal, Other What _________ _______________ How long __________ Where __________
Comments __________________________________________________________________
Our fees for urgent care generally run between _________ and _________and are expected to be paid at your appointment. Will that be OK with you?
I can make time specifically for you at _________________. Will that work for you? In case there are any schedule changes may I have a contact phone number? __________________________
New Exam Questions
[1] Marina Cove Consulting – Modification and reprinting approved. 10102017
“Thank you for calling Dr. ____________ office. This is ____________. How may I help you today?
Patient Name __________________________, Pronounced ________________
New Pt ______, Current Pt _______ Urgent Care ______
“Who may we thank for referring you to our office?” ______________________
Chief Complaint (their words) _____________________________________________
Urgent Care Questions: Discomfort, Tooth, Removable, Periodontal, Other What _________ _______________ How long __________ Where __________
Comments __________________________________________________________________
Our fees for urgent care generally run between _________ and _________and are expected to be paid at your appointment. Will that be OK with you?
I can make time specifically for you at _________________. Will that work for you? In case there are any schedule changes may I have a contact phone number? __________________________
New Exam Questions
- “So that I can make the appropriate appointment for you, when was your last dental visit and what was it for? ______________________________________________________
- “Our new patient exam includes a comprehensive exam by Dr. _________, necessary radiographs, and photographs. Plan on spending at least one hour and twenty minutes. We will determine what type of cleaning is indicated at your visit and schedule that at your convenience. Fees for your initial exam general are in the range of $ _________.
- Will you be utilizing any dental insurance benefits? Ins Company _________________________________
- I would like to send you a welcome packet and the needed forms that you can fill out before coming in. I can mail them, email them or you can fill them out on our website. Which would you prefer?
- Address ________________________________________________________________
- Email _________________________________________
- Phone ______________________________________
- Will you need any form of pre-medication before your dental visit?
- Pharmacy ___________________ Phone _______________
- “Let’s get you into the schedule. Would you be available on _________________ at _________________?
- ___________________________(patient name) we look forward to seeing you on ________________________. Is there anything else I can help you with today?
- Comments _________________________________________________________________________________________________________________________________________
- Staff Mbr _________ Pack sent ______ Date ________
[1] Marina Cove Consulting – Modification and reprinting approved. 10102017