The Durham Center :: Providers

The Durham Center
414 East Main Street
Durham, NC 27701
919-560-7200

Consumer Missed Appointment Follow Up

Provider agency name

LME client ID number

Client last name

Client first name

Client middle name

Client date of birth

Date of original appointment
(mm-dd-yyyy)

Time of original appointment
(hh:mm)

Do not submit this form to until you have taken at least one of these actions.

Click all that apply.

Visited the consumer's home

Followed up by telephone with the consumer

Rescheduled an office visit that the consumer attended

Made at least three unsuccessful attempts to contact the consumer

What was the consumer's response to any follow up contact you had with him/her?

Date of rescheduled appointment
(mm-dd-yyyy)

Time of rescheduled appointment
(hh:mm)

Name of person completing this form

Email address of person completing this form