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Free Abnormal Results Contact Attempt Record Form - PDF Form Download

Abnormal Results Contact Attempt Record Form Overall rating: ☆☆☆☆☆ 0 based on 0 reviews
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Download and use this form to track abnormal Results of your patient.

Abnormal Results Contact Attempt Record Form


Text Version of this Form

Abnormal Results Contact Attempt Record

 

Please note: All attempts to contact a patient must be recorded in the patient’s individual medical record at the time of the contact. This is a legal safeguard. Practice staff MUST NOT give out test results to patients unless expressly advised to by the PCP

 

Patient’s Name        
DOB        
Patient’s Physical

Initials

       
Urgency of consult        
Type of test, e.g. blood,

pap

       
Time, date, phone no. &

staff initials of 1st phone

call

       
Time, date, phone no. &

staff initials of 2nd phone

call

       
Time, date, phone no. &

staff initials of 3rd phone

call

       
Date 1st letter sent        
Mail returned?        
Date 2nd letter sent        
Mail returned?        
Date Registered Mail

Sent

       
Post office confirmation

received receipt

       

 

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