Patient 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 patient intake form for general healthcare
  • navigate_next Collect patient demographics, emergency contact details, and health concerns
  • navigate_next Customize the form by adding or removing fields as per your requirements
  • navigate_next Ensure compliance with PHI regulations by marking sensitive fields
  • navigate_next Include a signature field to obtain patient consent

Collect responses from your patients

Patient ID 1234567890
Patient Name John Doe
Date of Birth 01/01/1990
Gender Male
Marital Status Single
Patient Email example@example.com
Phone Number 123-456-7890
Address 123 Main St, City, State
Social Security Number 123-45-6789
Emergency Contact Name Emergency Contact Name
Emergency Contact Phone 123-456-7890
Emergency Contact Email emergency@example.com
What is the primary health concern? Chronic back pain
What are your goals that bring you to the clinic? To address my chronic back pain
By signing, you agree to the terms of hospitalization I agree to the terms of hospitalization
  • navigate_next Send the intake form to patients via email or provide a link on your website
  • navigate_next Allow patients to complete the form at their convenience and from any device
  • navigate_next Enable patients to save their progress and complete the form in multiple sessions
  • navigate_next Receive instant notifications when a patient submits the intake form
  • navigate_next Store patient responses securely in a centralized database

Track patient responses in a secure database

Assessment form builder
  • navigate_next Access and review patient responses anytime from a secure online database
  • navigate_next Search and filter responses based on patient information or date of submission
  • navigate_next Export patient data to PDF or CSV for offline access or further analysis
  • navigate_next Integrate with other healthcare systems to streamline patient management
  • navigate_next Ensure data security and compliance with HIPAA regulations

HIPAA compliance

Patient ID: 1234567890
Patient Name: ******
Date of Birth: ******
Gender: ******
Marital Status: ******
Patient Email: ******
Phone Number: ******
Address:******
Social Security Number: ******
Emergency Contact Name: ******
Emergency Contact Phone: ******
Emergency Contact Email: ******
What is the primary health concern?:Chronic back pain
What are your goals that bring you to the clinic?:To address my chronic back pain
By signing, you agree to the terms of hospitalization:
  • navigate_next Create a HIPAA compliant intake form to securely collect and store patient data
  • navigate_next Implement strict access controls and encryption to protect patient information
  • navigate_next Enable audit logs to track user activity and maintain data integrity
  • navigate_next Regularly update security measures to address emerging threats
  • navigate_next Train staff on HIPAA regulations and data privacy best practices

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

More...
close