Patient Orientation Checklist Form
Complete this checklist to ensure all key orientation steps have been covered with the patient.
Patient Full Name
*
First Name
Last Name
Orientation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Orientation Checklist
*
Introduced to staff and facility
Reviewed patient rights and responsibilities
Tour of key facility areas (restrooms, exits, waiting area)
Discussed emergency procedures and exits
Explained appointment scheduling and contact information
Answered patient questions
Other (please specify)
Additional Notes
Orientation Completed By (Staff Name)
*
Signature of Staff
*
Signature of Patient
*
Submit Checklist
Submit Checklist
Should be Empty: