Social Security Disability Consultative Exam Appointment Checklist Form
Use this checklist to prepare for your consultative exam appointment and confirm all necessary details.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Exam Location/Address
*
Checklist: Please confirm you have prepared the following items
Valid photo identification
Appointment letter or notification
List of current medications
Directions to the exam location
Arranged transportation
Do you require special accommodations for your appointment?
No
Yes (please specify below)
If yes, please specify any special accommodations needed
Who will be accompanying you (if anyone)?
Additional notes or questions for your appointment
Submit Checklist
Should be Empty: