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Patient Visit Agenda My name: Date of birth: Main reason for today’s visit: Other concerns I would like to discuss if there is time: Check all that apply: q I have prescriptions that need to be refilled q I need the attached forms filled out. q Other: Patient Preparation Checklist for Referrals q Do I know who I am seeing? q Do I know why I am seeing this person? q Do I know how I am getting there? q Do I have my questions for this person written down? q What do I need to prepare for this visit: o Bring medications? o Bring records and/or x-rays? o Change my usual eating? o Other? q Is there anything else I should know about the visit? q Will my insurance cover the visit? o If so, will there be co-pays or other charges? o If not, how is the cost of the visit being covered? Section 4.5.1 Implement–Patient Visit Agenda and Preparation Checklist Template - 1
