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 pediatric intake form
- Collect patient, parent/guardian, and insurance information
- Capture medical history, developmental history, and concerns of pediatric patients
- Allow parents/guardians to upload insurance cards and prescriptions
- 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. |
- Pre-populate patient details from your booking system to reduce errors
- Send an email invitation with a secure link for parents/guardians to complete the intake form
- Allow parents/guardians to save their progress and complete the form at a later time
- Set up an email template and send invitation emails to multiple parents/guardians with ease
- Send an email to parents/guardians 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 pediatric 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 parent/guardian submits the intake form
- 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. |
- 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
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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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