Consumer Doctors Log

Enter the full name of the consumer attending medical appointments

Instructions for Use:

  • Complete one log entry for each medical appointment
  • Have the physician or RN sign each entry during the visit
  • Use additional forms if more than 3 appointments are needed
  • Submit completed form within 24 hours of final appointment

Doctor Visit Log Entry #1

MM slash DD slash YYYY
Select the date of the medical appointment
Appointment Time
:
Enter the scheduled appointment time
Name of the physician or medical practice
Complete address of the medical facility
Brief notes about the visit (optional)
Clear Signature
Medical professional signature confirming visit attendance

Doctor Visit Log Entry #2

MM slash DD slash YYYY
Select the date of the medical appointment
Appointment Time
:
Enter the scheduled appointment time
Name of the physician or medical practice
Complete address of the medical facility
Brief notes about the visit (optional)
Clear Signature
Medical professional signature confirming visit attendance

Doctor Visit Log Entry #3

MM slash DD slash YYYY
Select the date of the medical appointment
Appointment Time
:
Enter the scheduled appointment time
Name of the physician or medical practice
Complete address of the medical facility
Brief notes about the visit (optional)
Clear Signature
Medical professional signature confirming visit attendance
This field is hidden when viewing the form
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.