Volunteer Patient Visit Notes

"*" indicates required fields

Please submit one form per patient.

Date*

Actual date of patient visit.

Volunteer Name*

Patient Medical Record Number*

Protect patient privacy by using ONLY the medial record number here.

Patient Initials*

Only use patient initials and double check for accuracy.

Type of Service*

Time In*

Enter the time you left your house.

Time Out*

Enter the time you left patient's house.

Mileage*

Enter the distance from your house to the patient’s location and home again (your round trip mileage) If you are visiting multiple patients at one location, only enter the mileage on the form for the FIRST patient you see at that location, and not the others.

Volunteer Notes (will be added to patient chart)*

Your “Visit Notes” can be brief – two sentences – or a small paragraph. This is up to you. The record just needs to show a brief summary of your visit and what volunteer task you completed such as respite, companionship, light house cleaning, etc. Please reach out to our Volunteer Coordinator with any questions or for suggestions for wording if you aren’t sure!

Please do not close this page until you get a confirmation that your submission was sent.

Name

This field is for validation purposes and should be left unchanged.

55459

(770) 558-6202

(770) 558-6202

Volunteer Patient Visit Notes