Medical Consultation Form Template

If you ever found a medical consultation form template on the internet, do you wonder what it is for? Well, a medical consultation form is very much useful for the doctors or the medical specialists that provide the medical service for the patients. It is used in order to fix the date of the consultation with the doctor clearly. Not only that, it’s used by the patient to fix easily the schedule of consultation with the doctor by sending the doctor request.

In the medical consultation request form, the patients need to provide some of the information about the problems they are now suffering. Thus, the medical specialist could provide the best treatment as possible for them. The form of the Medical consultation request form can be customized easily per need that you have as the patient. And here are two examples of medical consultation form:

  1. Simple form

The first example is the simplest medical consultation form and usually used as a medical consultation form for new patient. In this simple form, you need to fill in some information related to the personal information such as name, gender, age, and the contact number. After that, you will be asked by the form whether or not you’ve seen doctor for some illnesses. And the illnesses will be mentioned below, and you need to checklist the illness if you have. The illnesses are such high blood pressure, heart disease, high cholesterol, bleeding disorder, diabetes, etc.


  1. Medical Patient Consultation Form

    Medical Patient Consultation Form

The second is medical consultation request form. The form is like a letter. On the top left of the form, there is the doctor’s name. And then on the top right side, there is the logo of the clinic, hospital, or the institution. Then below, there is the address, phone, and email of the clinic. In this kind of medical consultation form template, you will write like a letter. First, you write TO: (the name of the doctor and the address), then there is the information about the condition of the patient with the medical problems. Then the date will be written in the office. And there is the signature and the date.


Medical Consultation Form Sample Download

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Medical Consultation Form Template free

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After that, there is a response from the doctor. Usually, the doctor will ask to consider the patients’ cardiovascular condition and the infectious disease’ status. And there is option whether the patient has infectious disease or not, and other medical information which is attached.