Use prebuilt template to create a comprehensive intake form for chiropractic care
Collect responses from your patients
- Send personalized email invitations to patients with a secure link to complete the intake form
- Allow patients to save their progress and complete the form at their convenience
- Automatically populate patient details from your booking system to reduce errors
- Receive email notifications with a copy of the patient's response when they submit the form
- Track and manage patient responses in a centralized dashboard
Track patient responses in Google Sheets
| Patient ID | user input |
| Phone number | user input |
| Subscriber Employer or Plan Sponsor | user input |
| Subscriber ID# | user input |
| Group # | user input |
| Group # | user input |
| Claim # | user input |
| Policy # | user input |
| Patient Signature | user input |
| What is the primary reason for your visit today? | user input |
| Is this condition interfering with: | Work,Sleep |
| If you have pain, please rate your level of pain over the last 24 hours | 5 |
| Have you received care for this problem before? Please explain. | user input |
| Chiropractor's Name | user input |
| Reason for seeking care | user input |
| Results | Good |
| Have you ever had: | Fracture,Major Surgery |
| Please list and describe all significant previous injuries, surgeries, illnesses and hospitalizations you may have had: (sprains, fractures, accidents, etc.) | user input |
| Please list any diseases, disorders, or major illnesses of biological family members. If deceased, from what? (ie: Cancer, diabetes, high blood pressure, stroke, etc.): | user input |
| Are you, or might you be pregnant? | 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 eat a well-balanced diet? | Yes |
| Do you drink water regularly? | Yes |
| Do you use, or have you in the past, used any of the following products: | Tobacco,Alcohol |
| Smoking Status | Never smoked |
| Alcohol Intake | None |
- Export patient responses to Google Sheets for easy record-keeping and analysis
- Create custom reports and filters to analyze patient data and track progress over time
- Integrate with other tools and systems using Google Sheets API for seamless data transfer
- Collaborate with your team by sharing access to the Google Sheets document
- Ensure data security with Google's robust privacy and security measures
HIPAA compliance
- Create a HIPAA compliant intake form to securely collect and store patient information
- Mark fields as Protected Health Information (PHI) to ensure data privacy and compliance
- Implement access controls and user permissions to limit data access to authorized personnel
- Encrypt data transmission and storage to protect patient information from unauthorized access
- Regularly audit and review security measures to maintain HIPAA compliance
These reviews are reproduced without modification from Google Workspace Marketplace.
July 27, 2023
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
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
Does not work
— Myles Sicuro
October 31, 2023
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
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
— Senthil Kumar
November 27, 2023
Yeah this is good for all
— luqman khan
July 10, 2023
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