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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.
25 per pack - Privacy Patient Sign-In 27 positions for Patients to fill personal information on removable strip.
Protect Your Spanish speaking and English speaking Patients' Privacy with the ACS Bilingual 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 Lt. Blue
Each form has 7 columns for each patient to fill out and 25 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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great quality and service 
