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 comprehensive medical intake form
- Collect patient details, medical history, allergies, and social history
- Capture insurance information and authorization for use and disclosure of PHI
- Allow patients to upload prescriptions and provide e-signature for consent forms
- Customize the form to fit your specific medical practice needs
Collect responses from your patients
|Primary Insured (subscriber)
|Relationship to Patient
|Secondary Policy Holder Name
|What are your current health concerns?
|Are you under the care of a physician?
|If hospitalized, please explain
|Are you currently taking any medications?
|Do you have any allergies?
|List any allergies you may have
|Do you presently or have you ever had:
|Do you use, or have you in the past, used any of the following products:
|Are you or could you be pregnant/nursing?
- Send an email invitation with a secure link for patients to complete their intake form
- 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
- Receive real-time notifications when a patient completes the intake 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
|Primary Insured (subscriber) :
|Relationship to Patient:
|Secondary Policy Holder Name:
|What are your current health concerns?:
|Are you under the care of a physician?:
|If hospitalized, please explain:
|Are you currently taking any medications?:
|Do you have any allergies? :
|List any allergies you may have:
|Do you presently or have you ever had::
|Anemia, Asthma, Diabetes
|Do you use, or have you in the past, used any of the following products::
|Are you or could you be pregnant/nursing?:
- 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 30, 2023
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November 27, 2023
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July 10, 2023
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