Dermatology intake form
22 reviews
24K+
Installs

Use our readymade template to create this Google form. Customize it further using our form builder.

Create your intake form

Assessment form builder
  • navigate_next Use prebuilt template to create a HIPAA compliant online dermatology intake form
  • navigate_next Collect patient, demography, emergency contact details, medical history
  • navigate_next Collect skin disease history, skin care routine, and cosmetic interests
  • navigate_next Gather information on allergies, medications, and social history
  • navigate_next Get signatures for consent for treatment, use of PHI, and notice of privacy practices

Collect responses from your patients

Patient ID user input
Date of Birth user input
Subscriber Employer or Plan Sponsor user input
Date signed 2023-08-08
What is the reason for today's visit? user input
When was your last skin check? user input
Do you have a family history of melanoma or other skin cancers? No
Do you wear sunscreen? Yes
If you use sunscreen, what is the SPF? user input
Are you currently in good health? Yes
Are you under the care of a physician? No
Have you had or currently have any of the following medical conditions: Anxiety,Depression
Have you had any serious illness/operation/ or been hospitalized? No
Are you currently taking any medications? No
List medications you are currently taking user input
Do you have any allergies? No
List any allergies you may have user input
Do you use, or have you in the past, used any of the following products: Tobacco,Alcohol
Smoking Status Never smoked
Alcohol Intake None
Are you or could you be pregnant/nursing? No
Patient Signature user input
Date Signed 2023-08-08
Patient Signature user input
Patient Signature user input
Date Signed 2023-08-08
  • navigate_next Pre-populate patient details from your booking system to reduce errors
  • navigate_next Send an email invitation with a secure link for patients to complete their intake
  • navigate_next Allow patients to save their progress and complete their form at a later time
  • navigate_next Set up an email template and send invitation emails to multiple patients with ease
  • navigate_next Send an email to the patients with a copy of their response when they submit the form

Track patient responses in Google Sheets

Assessment form builder
  • navigate_next Export patient responses to Google Sheets for easy record-keeping
  • navigate_next Create a custom workflow and manage your patient intake efficiently
  • navigate_next Use pre-built reports to easily keep track of patient progress over time
  • navigate_next Receive a copy of the response by email when a patient submits the intake form
  • navigate_next Use data in Google Sheets to integrate with EHR systems for seamless data transfer

HIPAA compliance

Patient ID: ******
Date of Birth:11/30/1899
Subscriber Employer or Plan Sponsor:11/30/1899
Date signed:8/8/2023
What is the reason for today's visit?:user input
When was your last skin check?:11/30/1899
Do you have a family history of melanoma or other skin cancers?: No
Do you wear sunscreen? : Yes
If you use sunscreen, what is the SPF?: user input
Are you currently in good health?: Yes
Are you under the care of a physician?: No
Have you had or currently have any of the following medical conditions:: Anxiety, Depression
Have you had any serious illness/operation/ or been hospitalized?: No
Are you currently taking any medications?: No
List medications you are currently taking:user input
Do you have any allergies? : No
List any allergies you may have:user input
Do you use, or have you in the past, used any of the following products:: Tobacco, Alcohol
Smoking Status: Never smoked
Alcohol Intake: None
Are you or could you be pregnant/nursing?: No
Patient Signature:
Date Signed:8/8/2023
Patient Signature:
Patient Signature:
Date Signed:8/8/2023
  • navigate_next Create a HIPAA compliant intake form to safely collect, store and access patient responses
  • navigate_next Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
  • navigate_next Mask PHI fields when exporting form responses to Google Sheets and sending them on email
  • navigate_next Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
  • navigate_next Limit access to patient data only for authorized personnel and minimize risk of data breaches

These reviews are reproduced without modification from Google Workspace Marketplace.

July 27, 2023

5 stars

I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!

— Royal Bush

July 23, 2023

5 stars

I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!

— Sol Evans

February 16, 2024

1 stars

Does not work

— Myles Sicuro

October 31, 2023

5 stars

We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!

— Chris Henesy

July 12, 2023

5 stars

It very friendly to used. I love it. For my case multiple signature needed. it's supporting

— Senthil Kumar

November 27, 2023

5 stars

Yeah this is good for all

— luqman khan

July 10, 2023

5 stars

We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.

— Joan S

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