Patient Encounter Form printable pdf download

Patient Encounter Form

Number:

__________________________________________

Date of Visit

______________________________

(MM/DD/YY):

Patient Information

Name:

_____________________________________________

Sex:

Age:

__________

Address:

___________________________________________

Date of Birth

______________________________

(MM/DD/YY):

Chief Complaint:

_____________________________________

Allergies:

__________________________________________

Lab Work Section

Clinician’s Name

Lab Tests Required

Results

_________________________________________________

Comments:

_________________________________________________

Pharmacy To Complete

_________________________________________________

Meds Issued (name/dose/quantity):

_________________________________________________

Referral to:

Special Instructions:

Clinician’s Signature:

________________________________

Patient Encounter Form