Virtual Care Appointment Preparation Checklist Form
Use this checklist to get ready for your upcoming virtual care appointment. Provide the details below to ensure a smooth and successful visit.
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider or Clinic Name
*
Is your device (computer, tablet, or smartphone) ready and fully charged?
*
Yes
No
Not sure
Is your internet connection stable and working?
*
Yes
No
Not sure
Preferred Virtual Meeting Platform
*
Please Select
Zoom
Microsoft Teams
Google Meet
Doxy.me
Other
What is the main reason for your visit or your primary symptoms? (Please describe in general terms only)
*
Current Medications (list medication names only, if any)
Do you have any specific questions or topics you want to discuss during your appointment?
Will you need technical assistance connecting to your virtual appointment?
No, I am comfortable with the technology
Yes, I might need some help
Not sure
Submit Checklist
Should be Empty: