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 patient intake form for general healthcare
- Collect patient demographics, emergency contact details, and health concerns
- Customize the form by adding or removing fields as per your requirements
- Ensure compliance with PHI regulations by marking sensitive fields
- 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 |
- Send the intake form to patients via email or provide a link on your website
- Allow patients to complete the form at their convenience and from any device
- Enable patients to save their progress and complete the form in multiple sessions
- Receive instant notifications when a patient submits the intake form
- Store patient responses securely in a centralized database
Track patient responses in a secure database
- Access and review patient responses anytime from a secure online database
- Search and filter responses based on patient information or date of submission
- Export patient data to PDF or CSV for offline access or further analysis
- Integrate with other healthcare systems to streamline patient management
- 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 |
- Create a HIPAA compliant intake form to securely collect and store patient data
- Implement strict access controls and encryption to protect patient information
- Enable audit logs to track user activity and maintain data integrity
- Regularly update security measures to address emerging threats
- Train staff on HIPAA regulations and data privacy best practices
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!
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July 12, 2023
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
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November 27, 2023
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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.
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