Unable to Reach Patient Log Form
Use this form to record attempts to contact a patient, the outcome of each attempt, and the follow-up plan.
Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Patient Record Reference
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Name / Nickname
Contact Attempt Log
Date and Time of Attempt
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Number of Attempts Made
*
Communication Method Used
*
Phone Call
Text Message
Voicemail
Email
Patient Portal
Other
Attempt Made By (Name or Role)
*
Internal Attempt Status
*
Please Select
Unanswered
Voicemail Left
Number Disconnected
Wrong Number
No Response to Text
Other
Reason and Outcome
Reason patient could not be reached
*
No answer
Voicemail not set up
Disconnected number
Wrong number
Full mailbox
Invalid contact details
Patient unavailable
Other
Additional details
Outcome of the attempt
*
Contact made
Left voicemail
Unable to leave message
Number disconnected
Information updated
Other
Follow-up Plan
Preferred callback method
*
Please Select
Phone
Text message
Email
Portal message
Other
Best time to contact
Hour Minutes
AM
PM
AM/PM Option
Next follow-up date and time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Urgent follow-up needed?
*
Yes
No
Next action planned
*
Please Select
Retry later
Update contact information
Notify provider
Send message through portal
Stop outreach
Other
Notes for future outreach
Submit
Should be Empty: