Doctor Appointment Form
Professional Doctor Appointment Form template for Adult Family Homes. Includes editable Word (.docx) and printable PDF formats.
[YOUR ADULT FAMILY HOME NAME HERE]
Doctor Appointment Form
TEMPLATE • Inspection-Ready AFH Standard
1. Reason for Visit & Pre-Appointment Vitals Log
This agreement is entered into on this _____ day of ____________, 20___, between [ADULT FAMILY HOME NAME] (Provider) and [RESIDENT / POA NAME].
2. Physician Diagnosis & Order Changes Section
FINANCIAL TERMSBase Rate & Payment Schedule: Resident agrees to pay Provider a monthly base fee of $______ payable in advance on the first (1st) day of each calendar month.
3. New Medication Prescriptions & Lab Requests
Provider Signature / Date
Resident / POA Signature / Date
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Document Section Breakdown (4 Sections)
Reason for Visit & Pre-Appointment Vitals Log
Current symptoms, blood pressure, weight, temperature, and caregiver questions for doctor.
Physician Diagnosis & Order Changes Section
Doctor diagnosis update, treatment changes, and activity restriction notes.
New Medication Prescriptions & Lab Requests
New medication orders, dosage, start dates, and required follow-up blood work.
Follow-Up Appointment & Provider Signature
Next scheduled visit date, physician printed name, and clinic signature stamp.
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