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
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October 31, 2023
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February 16, 2024
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July 12, 2023
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November 27, 2023
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July 10, 2023
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