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 dermatology intake form
- Collect patient, demography, emergency contact details, medical history
- Collect skin disease history, skin care routine, and cosmetic interests
- Gather information on allergies, medications, and social history
- Get signatures for consent for treatment, use of PHI, and notice of privacy practices
Collect responses from your patients
|Date of Birth
|Subscriber Employer or Plan Sponsor
|What is the reason for today's visit?
|When was your last skin check?
|Do you have a family history of melanoma or other skin cancers?
|Do you wear sunscreen?
|If you use sunscreen, what is the SPF?
|Are you currently in good health?
|Are you under the care of a physician?
|Have you had or currently have any of the following medical conditions:
|Have you had any serious illness/operation/ or been hospitalized?
|Are you currently taking any medications?
|List medications you are currently taking
|Do you have any allergies?
|List any allergies you may have
|Do you use, or have you in the past, used any of the following products:
|Are you or could you be pregnant/nursing?
- 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
|Date of Birth:
|Subscriber Employer or Plan Sponsor:
|What is the reason for today's visit?:
|When was your last skin check?:
|Do you have a family history of melanoma or other skin cancers?:
|Do you wear sunscreen? :
|If you use sunscreen, what is the SPF?:
|Are you currently in good health?:
|Are you under the care of a physician?:
|Have you had or currently have any of the following medical conditions::
|Have you had any serious illness/operation/ or been hospitalized?:
|Are you currently taking any medications?:
|List medications you are currently taking:
|Do you have any allergies? :
|List any allergies you may have:
|Do you use, or have you in the past, used any of the following products::
|Are you or could you be pregnant/nursing?:
- 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.
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