SoFHA Patient Forms

Appointment Agenda Form

Description:

The SoFHA Primary Care of Elizabethton appointment agenda form.

Code:

15.102

Issued:

02/17/2021

Revision:

Revised:

N/A

Patient Information

Name First, MI, Last

Date of Birth

Agenda

What concerns do you want to discuss at your appointment today?

Are you experiencing any symptoms you want your provider to be aware of?

What Pharmacy do you use (local and/or mail order)?

What refill frequency do you use?

90-day

30-day

Do you need any refills of these medications or new medications?

Yes

Do you have concerns related to paying for your prescription drugs?

Yes

Providers outside of SoFHA that you’ve seen since last visit (specialist, urgent care, etc.):

Do you need a work/school excuse for today’s visit?

Yes

Signature

By typing your name in the signature fields below, you agree that your submission of this form, via the "Submit Form" button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Patient/Guardian Signature