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.
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