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 podiatry intake form
- Collect patient, demography, emergency contact details, medical history
- Collect foot-related concerns, pain level, and lifestyle impact
- Allow patients to upload their driver’s id, prescriptions for medications
- Get signatures for consent for treatment, notice of privacy practices, use of PHI
Collect responses from your patients
| Patient ID | user input |
| Patient Name | user input |
| Patient Email | user input |
| Patient Phone Number | user input |
| Marital Status | user input |
| Date of birth | user input |
| Address | user input |
| Emergency Contact Name | user input |
| Emergency Contact Phone | user input |
| Relationship | user input |
| Primary Doctor | user input |
| Location | user input |
| Date of service | user input |
| Primary Insured (subscriber) | user input |
| Relationship to Patient | user input |
| Date of Birth | user input |
| Phone number | user input |
| Subscriber Employer or Plan Sponsor | user input |
| Insurance Company | user input |
| Subscriber ID# | user input |
| Secondary Policy Holder Name | user input |
| Date of Birth | user input |
| Subscriber Employer or Plan Sponsor | user input |
| Phone number | user input |
| Insurance Company | user input |
| Patient Signature | user input |
| Date signed | 2023-08-08 |
| What are the medical issues concerning your foot, ankle and legs? | user input |
| Result of accident or work injury? | No |
| On a scale of 1-10, what is your level of pain? | user input |
| Pain Type: | user input |
| Since the time your pain or problem began, has it: | user input |
| How has this problem affected your lifestyle or ability to work? | user input |
| Have you visited a podiatrist before? | user input |
| Name of the podiatrist | user input |
| Last appointment date | user input |
| Are you a diabetic? | No |
| What athletic activities do you participate in and how often? | user input |
| Do you get leg cramps after activity? | No |
| Does foot pain limit your desired activities? | user input |
| Do you have any difficult walking? | user input |
| Any pain in the calves or buttocks when walking? | user input |
| Which of these foot problems do you have or had in the past? | Corns/Calluses,Fungal Toenails |
| Are you currently experiencing any of the following symptoms? | Fever,Muscle aches |
| Are you currently in good health? | Yes |
| Are you under the care of a physician? | No |
| Have you or any family member had or currently have any of these medical conditions: | High Blood Pressure,Diabetes |
| Have you had any serious illness/operation/ or been hospitalized? | No |
| Are you currently taking any medications? | No |
| Upload prescriptions | user input |
| Do you have any allergies? | user input |
| List any allergies you may have | user input |
| Do you use, or have you in the past, used any of the following products: | Tobacco,Alcohol |
| Smoking Status | Never smoked |
| Alcohol Intake | None |
| Are you or could you be pregnant/nursing? | No |
| Patient Signature | user input |
| Date Signed | 2023-08-08 |
| Patient Signature | user input |
| Date Signed | 2023-08-08 |
| Date Signed | user input |
- 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
| Patient ID: | ****** |
| Patient Name: | ****** |
| Patient Email: | ****** |
| Patient Phone Number: | ****** |
| Marital Status: | user input |
| Date of birth: | 11/30/1899 |
| Address: | user input |
| Emergency Contact Name: | user input |
| Emergency Contact Phone: | user input |
| Relationship: | user input |
| Primary Doctor: | user input |
| Location: | user input |
| Date of service: | 11/30/1899 |
| Primary Insured (subscriber) : | user input |
| Relationship to Patient: | user input |
| Date of Birth: | 11/30/1899 |
| Phone number: | user input |
| Subscriber Employer or Plan Sponsor: | user input |
| Insurance Company: | user input |
| Subscriber ID#: | user input |
| Secondary Policy Holder Name: | user input |
| Date of Birth: | 11/30/1899 |
| Subscriber Employer or Plan Sponsor: | 11/30/1899 |
| Phone number: | user input |
| Insurance Company: | 11/30/1899 |
| Date signed: | 8/8/2023 |
| What are the medical issues concerning your foot, ankle and legs?: | user input |
| Result of accident or work injury?: | No |
| On a scale of 1-10, what is your level of pain?: | 0 |
| Pain Type:: | user input |
| Since the time your pain or problem began, has it:: | user input |
| How has this problem affected your lifestyle or ability to work?: | user input |
| Have you visited a podiatrist before?: | user input |
| Name of the podiatrist: | user input |
| Last appointment date: | 11/30/1899 |
| Are you a diabetic?: | No |
| What athletic activities do you participate in and how often?: | user input |
| Do you get leg cramps after activity?: | No |
| Does foot pain limit your desired activities?: | user input |
| Do you have any difficult walking?: | user input |
| Any pain in the calves or buttocks when walking?: | user input |
| Which of these foot problems do you have or had in the past?: | Corns/Calluses, Fungal Toenails |
| Are you currently experiencing any of the following symptoms?: | Fever, Muscle aches |
| Are you currently in good health?: | Yes |
| Are you under the care of a physician?: | No |
| Have you or any family member had or currently have any of these medical conditions:: | High Blood Pressure, Diabetes |
| Have you had any serious illness/operation/ or been hospitalized?: | No |
| Are you currently taking any medications?: | No |
| Upload prescriptions: | user input |
| Do you have any allergies? : | user input |
| List any allergies you may have: | user input |
| Do you use, or have you in the past, used any of the following products:: | Tobacco, Alcohol |
| Smoking Status: | Never smoked |
| Alcohol Intake: | None |
| Are you or could you be pregnant/nursing?: | No |
| Date Signed: | 8/8/2023 |
| Date Signed: | 8/8/2023 |
| Date Signed: | 11/30/1899 |
- 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