Pediatric intake form
21 reviews
21K+
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 HIPAA compliant online pediatric intake form
  • navigate_next Collect patient, parent/guardian, and insurance information
  • navigate_next Capture medical history, developmental history, and concerns of pediatric patients
  • navigate_next Allow parents/guardians to upload insurance cards and prescriptions
  • navigate_next Get signatures for consent for treatment, notice of privacy practices, use of PHI

Collect responses from your patients

Primary Insured (subscriber) John Doe
Has your child ever sustained an injury playing organized sports? No
Did you experience any complications during your pregnancy? Back/other pain,Gestational diabetes
Were any medications or drugs used in the pregnancy? Alcohol,Smoking
Were there any problems during the delivery? No
Were there any medical concerns when the child was a newborn? No
Were you ever concerned about your child’s development? No
Does your child currently receive any special therapy? Speech therapy,Occupational therapy
Do you have any concerns about your child’s behavior? ADHD,ADD
Has your child ever suffered from any of the below Headaches,Heart Trouble
Have you vaccinated your child? Yes, as scheduled
Has the child had any serious illness, operation, or been hospitalized? No
Does your child have any allergies? No
Family history Family member 1: Diabetes, Allergies, Medication A. Family member 2: Asthma, Surgery B.
  • navigate_next Pre-populate patient details from your booking system to reduce errors
  • navigate_next Send an email invitation with a secure link for parents/guardians to complete the intake form
  • navigate_next Allow parents/guardians to save their progress and complete the form at a later time
  • navigate_next Set up an email template and send invitation emails to multiple parents/guardians with ease
  • navigate_next Send an email to parents/guardians with a copy of their response when they submit the form

Track patient responses in Google Sheets

Assessment form builder
  • navigate_next Export patient responses to Google Sheets for easy record-keeping
  • navigate_next Create a custom workflow and manage your pediatric intake efficiently
  • navigate_next Use pre-built reports to easily keep track of patient progress over time
  • navigate_next Receive a copy of the response by email when a parent/guardian submits the intake form
  • navigate_next Use data in Google Sheets to integrate with EHR systems for seamless data transfer

HIPAA compliance

Primary Insured (subscriber) : John Doe
Has your child ever sustained an injury playing organized sports?: No
Did you experience any complications during your pregnancy?: Back/other pain, Gestational diabetes
Were any medications or drugs used in the pregnancy?: Alcohol, Smoking
Were there any problems during the delivery? : No
Were there any medical concerns when the child was a newborn?: No
Were you ever concerned about your child’s development?: No
Does your child currently receive any special therapy?: Speech therapy, Occupational therapy
Do you have any concerns about your child’s behavior? : ADHD, ADD
Has your child ever suffered from any of the below: Headaches, Heart Trouble
Have you vaccinated your child?: Yes, as scheduled
Has the child had any serious illness, operation, or been hospitalized?: No
Does your child have any allergies? : No
Family history:Family member 1: Diabetes, Allergies, Medication A. Family member 2: Asthma, Surgery B.
  • navigate_next Create a HIPAA compliant intake form to safely collect, store and access patient responses
  • navigate_next Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
  • navigate_next Mask PHI fields when exporting form responses to Google Sheets and sending them on email
  • navigate_next Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
  • navigate_next 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

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 30, 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

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