Patient Transfer Report Form
Date of Interaction
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Practice Name
*
Practice Email
*
Patient's Last Name
*
Patient's First Name
*
Treatment Cost
Was the patient contacted within 10 minutes?
*
Was the patient contacted within 10 minutes?
Yes
No
NA
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List is empty.
Did the patient get approved?
*
Did the patient get approved?
Yes
No
Not Yet - Pending Financing
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List is empty.
Amount Approved (if $0 - type NA)
*
Summary of Interaction / Action
*
Patient Status
*
Patient Status
Qualified - Patient Pre-approved
Qualified - Paying Cash
Qualified - Paying Cash + Financing
Qualified - Financing
Qualification Process Handled By Practice
Deposit Paid
Pending
Scheduled Next Appointment
Other
Not Interested (Price, Doctor or other)
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List is empty.
Next Steps
*
Agent First Name
*
Agent Last Name
*
Submit Report