Patient Intake Form Template

Benefits of Using This Patient Intake Form Template

Printable Forms

Thinking about how to collect information offline? Our platform allows hospitals to take printouts of the intake form. This will help you to collect responses from patients right in the hospital. SurveySparrow also provides different orientation options and paper sizes for better presentation. You can export it as a pdf file. Customize the printed form with your logo in the footer with higher pricing plans.

Mobile Intake Form

Create conversational intake forms that are mobile-friendly because most people use their mobile phones to fill out forms easily. Your patients or bystanders can access this mobile intake form while traveling or at the hospital. Our templates are compatible with any device- be it a tablet, desktop, or mobile.

Use this Patient Registration Form Template to collect information from patients before admission

Skip/Display Logic

With our Skip/Display logic, you can ask only relevant questions to your patients. For instance, if your patient chooses consultation under a specific department, then redirect them to only those physicians who are specialized in it using our display logic. Similarly, if your patient selects they are not allergic to some medicines, you can use skip logic to spare them from filling in questions related to the side effects of treatment.

130+ Languages Supported

SurveySparrow allows you to collect responses from any language. This template supports 130+ languages and comes with an inbuilt Google translator. You can also use the translate editor to preview your questions in a specific language and edit them accordingly. This way you will get more patient intake from across the globe.

Keep Patient Data Safe With HIPAA Compliance

HIPAA compliance will help hospitals to protect patient data and minimize the risk of any data breaches. Your patients’ privacy & security is our top priority. SurveySparrow enforces and maintains the appropriate administrative, technical, and physical safeguards for ensuring the confidentiality, security, integrity, and privacy of your patients. And in the capacity of a Business Associate throughout the duration of providing services to our healthcare customers, SurveySparrow platform enables HIPAA compliance to covered entities.

We ensure our platform is HIPAA compliant through:

• Role-based access control - Multi-layered access control for owner, admin, and contributors. The admin has complete control of the account and the users, with features such as roles & access.
• Encryption - All data is encrypted in transit, end to end, and at rest using industry-standard Advanced Encryption Standard (AES) encryption using 256-bit keys to protect data encryption.
• Two-factor authentication - With the 2-factor authentication, users require the security code to log in to the SurveySparrow account. Even if someone finds your password, they cannot log in without your security code.
• Person or Entity Authentication - SurveySparrow has a policy that describes the process of verifying a person’s identity before unlocking their account, resetting their password, and/or providing access to ePHI.

Want to know patient feedback? Check out this Hospital Feedback Form Template

How to Use This Patient Intake Form Template

Step 1: Customize

Scroll up, click on ‘Use this Template’, and sign up to create a customized intake form. Change up the background, font, and even personalize the welcome and thank-you pages according to your choice. Need text inspiration? Let AI Wings rephrase questions or descriptions! 

Step 2: Integrate

Streamline your workflow by integrating with essential apps. Sync forms to Google Sheets, automate email follow-ups with Mailchimp and unlock a range of possibilities with SurveySparrow’s vast integration library.

Step 3: Share

Whether it’s through a unique link, website embed, email invite, or a QR code, our platform offers diverse sharing options to reach your customers wherever they are.

Step 4: Results

Export responses to CSV for offline analysis and use SurveySparrow’s dashboard for segmentation and visualization. Interpret the form efficiently for further contact and treatments.