Medical Appointment No-Show Report
Use this form to report a missed medical appointment, document reminder and contact attempts, note the reason for the no-show, and record any follow-up or rescheduling.
Patient and Appointment Details
Patient Full Name
*
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Record Identifier
Primary Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Email Address
example@example.com
Department / Clinic Name
*
Provider / Doctor Name
*
Appointment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment Time
*
Hour Minutes
AM
PM
AM/PM Option
Appointment Type
*
Consultation
Follow-up
Procedure
Imaging
Lab
Other
Location / Site
No-Show Report Details
Appointment Outcome
*
Arrived
No-Show
Canceled in Advance
Rescheduled
Date and Time Recorded
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reported By (Staff Name and Role)
*
Check-in Cutoff Time or Missed Window
Incident Summary / Notes
First No-Show for This Appointment?
Yes
No
Unknown
Reason and Contact Attempt Follow-Up
Reason for Missed Appointment
*
Transportation issue
Illness
Forgot
Work conflict
Family emergency
Unable to reach patient
Other
Explanation / Additional Details
Reminder Attempts Made Before Appointment
Phone call
SMS
Email
Portal message
Postcard
None
Number of Contact Attempts
Outcome of Outreach
*
Please Select
Reached
Left voicemail
No answer
Invalid number
Patient requested reschedule
Rescheduling Offered or Completed
Yes
No
Offered but not completed
Follow-Up, Acknowledgment, and Internal Notes
Preferred Follow-Up Action
*
Call back
Reschedule
Send reminder
Discharge review
No further action
Preferred 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
Internal Staff Notes
Confirmation
*
I confirm this report is accurate and the follow-up information may be used for care coordination.
Submit Report
Should be Empty: