I have been using a paper version of this for for some time (The Dental Record WSDA). I have heavily altered the page, but it is copyrighted, so not sure how to present this.
I plan to use this with the "new patient" automation trigger.
The flow goes like this:
1) The patient calls; Front desk enters in the name address etc. detail
2) Create new appointment which goes on the pinboard
3) This Sheet Pops up
Because creating rapport is so important, I will probably advised the fd to get the majority of the address and insurance info after finding our what the problem is.

http://www.flickr.com/photos/40082944@N06/5589724496