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  Home > MEDICAL > Medical Forms > HIPAA Forms >

Bilingual Privacy Patient Sign-In
Bilingual Privacy Patient Sign-In

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Buy 3 packs of this Item and get FREE SHIPPING!
Less than 3 packs Flat Shipping Rate $9.95
List Price: $65.00
Your Price: $39.50
You Save $25.50!
Unit Qty: 125
Unit: pack
Overall Dimensions: 8-1/2" W x 11"

Product Code: APSGN-B

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Description Freight, Returns & Sales Tax Policies
The ACS Bilingual Patient Sign-In Sheets now have 27 sign in positions!

Are you getting the best value for your Patient Sign-In Sheets?

Most sign-in sheets have 20, 23 or 25 sign-in positions.
With ACS you get 27 sign-in positions per sheet which equals 250 more sign-ins per pack of 125.
  • 20 positions / 125 sheet pack = 2,500 sign-ins
  • 23 positions 125 sheet pack = 2,875 sign-ins
  • 25 positions / 125 sheet pack = 3,125 sign-ins
  • 27 positions / ACS Sign-in 125 sheet pack = 3,375 sign-ins.
More value for your Dollar.

Instructions on how to use this form are printed in English and Spanish on the back of each form.

  • How to use this form:
    • The 27 patient signature lines are a peel off adhesive label.
    • The Signature labels are numbered 1-27.
    • Patient signs in on the next available signature line
    • Their information is transferred through a carbonless sheet to a patient log sheet on the back of the form.
    • If you use the number to call the patient back to the exam room, instruct the patient after signing to remove the number from the left-hand column next to their signature line.
    • The receptionist then may peel off the precut signature line of patient information and apply it to the patient flow chart.
    • The patient information is not visible to other patients at this point. The security cover sheet (part 2 of the form) says "Please Use Next Line".
    • After completing an entire sheet or at the end of each day, separate the sheet by breaking the snap-set at the top and bottom perforations. Discard the top two sheets, you now have a complete, private list of all patients and their information. You can use these complete lists for reporting, daily audits or office records.

    25 per pack - Privacy Patient Sign-In 27 positions for Patients to fill personal information on removable strip.

    Protect Your Spanish speaking and English speaking Patients' Privacy with the
    ACS Bilingual Sign-in Sheets for less than $.011 per patient sign in.

    Patients fill personal information on removable strip. Carbon sheet transfers information to the back so other patients do not see previous patient’s information Meets HIPAA Requirements
    Available in Lt. Blue

    Each form has 7 columns for each patient to fill out and 25 patient positions to fill out on a numbered slip, when finished filling out they remove the slip and hand to the receptionist leaving a blank space on sign in sheet front page. The information is transferred via carbon paper to a master log. When patient removes the slip, that space is blank and the patient information is protected behind the carbon paper, available only for office use.

    1) Number
    2) Patient Name,
    3) Appointment time,
    4) Arrival Time
    5) Appointment With
    6) New Patient check column
    7) Any changes to patient information since last visit.
Average Customer Review: 5 of 5 Total Reviews: 2 Write a review.

  0 of 0 people found the following review helpful:
Most Sign Ins June 14, 2016
Reviewer: Jane from Bloomington, IN  
most sign in positions i have been able to find as well as best price, free shipping and 10% off my order..

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  1 of 1 people found the following review helpful:
Now HIPAA Compiant June 14, 2016
Reviewer: Elizabeth Moore from Piqua, Ohio  
We were so happy to find this product it is easy to use and have had several patients comment that they appreciate the fact we are protecting their privacy.... : )

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