Use prebuilt template to create a comprehensive intake form for chiropractic care
Collect responses from your patients
- Send personalized email invitations to patients with a secure link to complete the intake form
- Allow patients to save their progress and complete the form at their convenience
- Automatically populate patient details from your booking system to reduce errors
- Receive email notifications with a copy of the patient's response when they submit the form
- Track and manage patient responses in a centralized dashboard
Track patient responses in Google Sheets
| Patient ID | user input |
| Phone number | user input |
| Subscriber Employer or Plan Sponsor | user input |
| Subscriber ID# | user input |
| Group # | user input |
| Group # | user input |
| Claim # | user input |
| Policy # | user input |
| Patient Signature | user input |
| What is the primary reason for your visit today? | user input |
| Is this condition interfering with: | Work,Sleep |
| If you have pain, please rate your level of pain over the last 24 hours | 5 |
| Have you received care for this problem before? Please explain. | user input |
| Chiropractor's Name | user input |
| Reason for seeking care | user input |
| Results | Good |
| Have you ever had: | Fracture,Major Surgery |
| Please list and describe all significant previous injuries, surgeries, illnesses and hospitalizations you may have had: (sprains, fractures, accidents, etc.) | user input |
| Please list any diseases, disorders, or major illnesses of biological family members. If deceased, from what? (ie: Cancer, diabetes, high blood pressure, stroke, etc.): | user input |
| Are you, or might you be pregnant? | No |
| Are you currently taking any medications? | No |
| List medications you are currently taking | user input |
| Do you have any allergies? | No |
| List any allergies you may have | user input |
| Do you eat a well-balanced diet? | Yes |
| Do you drink water regularly? | Yes |
| Do you use, or have you in the past, used any of the following products: | Tobacco,Alcohol |
| Smoking Status | Never smoked |
| Alcohol Intake | None |
- Export patient responses to Google Sheets for easy record-keeping and analysis
- Create custom reports and filters to analyze patient data and track progress over time
- Integrate with other tools and systems using Google Sheets API for seamless data transfer
- Collaborate with your team by sharing access to the Google Sheets document
- Ensure data security with Google's robust privacy and security measures
HIPAA compliance
- Create a HIPAA compliant intake form to securely collect and store patient information
- Mark fields as Protected Health Information (PHI) to ensure data privacy and compliance
- Implement access controls and user permissions to limit data access to authorized personnel
- Encrypt data transmission and storage to protect patient information from unauthorized access
- Regularly audit and review security measures to maintain HIPAA compliance
These reviews are reproduced without modification from Google Workspace Marketplace.
May 30, 2025
Besides the fact that one gets billed $216 monthly, Support took a long time to try and get things to work. Trying to get things signed on a form was such an issue and through out formatting. Way over priced, support that you have to wait till the next day to get one thing sorted and not sorted, back and forth the whole time. Frustrating customers and damage to business. I will not reccommend this company to anyone. Try JotForms so much better, and you can do much more for a fraction of the cost per year not per month.
— Francois Ohsiek
June 3, 2025
Hi Francois, sorry you had a frustrating experience with the formatting. Just to clarify, the plan you’re on is $216 per year, not per month. You signed up for the Formesign Esignature paid plan on May 8, 2024, and since you also needed to sign agreements, we provided access to our Formesign - Fillable PDF add-on at no extra cost. Regarding formatting: when working with Google Docs templates, we recommend using lists instead of indents and setting up layouts with tables for images, rather than inserting images directly. This helps maintain proper formatting. To assist, we also created and shared a sample template as a reference. You had asked us to make edits on your behalf, which we’re not able to do for security reasons. However, we did reach out and invited you to join a scheduled Zoom call to walk through the process — as we’ve done several times over the past year — but we didn’t receive a response. Update: To make things easier for all users, we have just launched the new document editor in Formesign that will allow agreements to be created directly, without relying on Google Docs.
— Formfacade
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
July 12, 2023
It very friendly to used. I love it. For my case multiple signature needed. it's supporting
— Senthil Kumar
February 16, 2024
Does not work
— Myles Sicuro
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