Use our readymade template to create this Google form. Customize it further using our form builder.
Create your intake form
- Use prebuilt template to create a HIPAA compliant online dermatology intake form
- Collect patient, demography, emergency contact details, medical history
- Collect skin disease history, skin care routine, and cosmetic interests
- Gather information on allergies, medications, and social history
- 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 |
- Pre-populate patient details from your booking system to reduce errors
- Send an email invitation with a secure link for patients to complete their intake
- Allow patients to save their progress and complete their form at a later time
- Set up an email template and send invitation emails to multiple patients with ease
- Send an email to the patients with a copy of their response when they submit the form
Track patient responses in Google Sheets
- Export patient responses to Google Sheets for easy record-keeping
- Create a custom workflow and manage your patient intake efficiently
- Use pre-built reports to easily keep track of patient progress over time
- Receive a copy of the response by email when a patient submits the intake form
- 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 |
| Date Signed: | 8/8/2023 |
| Date Signed: | 8/8/2023 |
- Create a HIPAA compliant intake form to safely collect, store and access patient responses
- Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
- Mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
- 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
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July 23, 2023
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February 16, 2024
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October 31, 2023
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November 27, 2023
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July 10, 2023
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