Sample Telephone Message Form
Telephone Triage/Message Form [Sample]
Message taken by:
Date Time Patient Name
Problem/Patient Complaint:
Current Medications
Caller’s name if not patient:
Relationship to patient:
Other Medical Problems
Allergies
Phone #
Patient’s A
g
e Weight
Work Phone #
Pregnant? Primary Care Physician
Cell Phone #
From _____am/pm To _____ am/pm
Patient can be reached
at home on cell at work
Problem/Patient Complaint (cont. if necessary):
Medication refill (circle) Medication
Pharmacy Name Phone #
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