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 patient intake form for general healthcare
- Collect patient demographics, emergency contact details, and health concerns
- Customize the form by adding or removing fields as per your requirements
- Ensure compliance with PHI regulations by marking sensitive fields
- Include a signature field to obtain patient consent
Collect responses from your patients
| Patient ID | 1234567890 |
| Patient Name | John Doe |
| Date of Birth | 01/01/1990 |
| Gender | Male |
| Marital Status | Single |
| Patient Email | example@example.com |
| Phone Number | 123-456-7890 |
| Address | 123 Main St, City, State |
| Social Security Number | 123-45-6789 |
| Emergency Contact Name | Emergency Contact Name |
| Emergency Contact Phone | 123-456-7890 |
| Emergency Contact Email | emergency@example.com |
| What is the primary health concern? | Chronic back pain |
| What are your goals that bring you to the clinic? | To address my chronic back pain |
| By signing, you agree to the terms of hospitalization | I agree to the terms of hospitalization |
- Send the intake form to patients via email or provide a link on your website
- Allow patients to complete the form at their convenience and from any device
- Enable patients to save their progress and complete the form in multiple sessions
- Receive instant notifications when a patient submits the intake form
- Store patient responses securely in a centralized database
Track patient responses in a secure database
- Access and review patient responses anytime from a secure online database
- Search and filter responses based on patient information or date of submission
- Export patient data to PDF or CSV for offline access or further analysis
- Integrate with other healthcare systems to streamline patient management
- Ensure data security and compliance with HIPAA regulations
HIPAA compliance
| Patient ID: | 1234567890 |
| Patient Name: | ****** |
| Date of Birth: | ****** |
| Gender: | ****** |
| Marital Status: | ****** |
| Patient Email: | ****** |
| Phone Number: | ****** |
| Address: | ****** |
| Social Security Number: | ****** |
| Emergency Contact Name: | ****** |
| Emergency Contact Phone: | ****** |
| Emergency Contact Email: | ****** |
| What is the primary health concern?: | Chronic back pain |
| What are your goals that bring you to the clinic?: | To address my chronic back pain |
- Create a HIPAA compliant intake form to securely collect and store patient data
- Implement strict access controls and encryption to protect patient information
- Enable audit logs to track user activity and maintain data integrity
- Regularly update security measures to address emerging threats
- Train staff on HIPAA regulations and data privacy best practices
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