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 optometry intake form
- Collect patient, demography, emergency contact details, medical history
- Collect vision insurance and medical insurance information
- Capture visual needs, glasses history, contacts history, ocular history
- Obtain patient consent for use and disclosure of protected health information
Collect responses from your patients
| Insured Name | Dr. Smith |
| Do you presently wear glasses? | Yes |
| How often do you replace or dispose of your contact lenses? | Daily |
| What is your typical wearing schedule days/week: | 8 |
| Are you in need of new contact lenses? | No |
| What is the reason for today's visit? | Routine eye checkup |
| What are your current concerns regarding your eyes and vision? | Redness,Burning,Itching |
| Have you or any family member had or have been diagnosed with any of the following conditions? | Cataracts,Glaucoma |
| Are you currently in good health? | Yes |
| Are you currently taking any medications? | Yes |
| List medications you are currently taking | None |
| Do you have any allergies? | No |
| List any allergies you may have | None |
| Do you use, or have you in the past, used any of the following products: | Tobacco,Alcohol |
| If yes to any of the above choices, please list how much/how often: | Occasionally |
| Are you or could you be pregnant/nursing? | No |
| 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
| Insured Name: | Dr. Smith |
| Do you presently wear glasses?: | Yes |
| How often do you replace or dispose of your contact lenses?: | Daily |
| What is your typical wearing schedule days/week:: | 8 |
| Are you in need of new contact lenses?: | No |
| What is the reason for today's visit?: | Routine eye checkup |
| What are your current concerns regarding your eyes and vision?: | Redness, Burning, Itching |
| Have you or any family member had or have been diagnosed with any of the following conditions?: | Cataracts, Glaucoma |
| Are you currently in good health?: | Yes |
| Are you currently taking any medications?: | Yes |
| List medications you are currently taking: | None |
| Do you have any allergies? : | No |
| List any allergies you may have: | None |
| Do you use, or have you in the past, used any of the following products:: | Tobacco, Alcohol |
| If yes to any of the above choices, please list how much/how often:: | Occasionally |
| Are you or could you be pregnant/nursing?: | No |
| 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 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