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Colors & Features
- How to Use This Form:
- The 27 patient signature lines are a peel off adhesive label.
- The Signature labels are numbered 1-27.
- Patient signs in on the next available signature line
- Their information is transferred through a carbonless sheet to a patient log sheet on the back of the form.
- If you use the number to call the patient back to the exam room, instruct the patient after signing to remove the number from the left-hand column next to their signature line.
- The receptionist then may peel off the precut signature line of patient information and apply it to the patient flow chart.
- The patient information is not visible to other patients at this point. The security cover sheet (part 2 of the form) says "Please Use Next Line".
- After completing an entire sheet or at the end of each day, separate the sheet by breaking the snap-set at the top and bottom perforations. Discard the top two sheets, you now have a complete, private list of all patients and their information. You can use these complete lists for reporting, daily audits or office records.
Protect Your Patients' Privacy with ACS Sign-in Sheets for less than $.011 per patient sign in.
Patients - fill personal information on removable strip. Carbon sheet transfers
- information to the back so other patients do not see previous patient’s
- information Meets HIPAA Requirements
Available in Salmon, Lt. Blue, Lt Green.
Each form has 7 columns for each patient to fill out and 27 - patient positions to fill out on a numbered slip, when finished filling
- out they remove the slip and hand to the receptionist leaving a blank
- space on sign in sheet front page. The information is transferred via
- carbon paper to a master log. When patient removes the slip, that space
- is blank and the patient information is protected behind the carbon
- paper, available only for office use.
Columns:
1) Number
2) Patient Name,
3) Appointment time,
4) Arrival Time
5) Appointment With
6) New Patient check column
7) Any changes to patient information since last visit.
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HIPAA compliant sign in sheets 
