Interactive sample
This is what the patient fills out on their phone the night before. Step through it the way they would.
Sample data, and nothing to type into. The answers below are invented and the fields are deliberately not editable, so there is no way to put real patient information into this page. Nothing is collected, stored or sent.
Routed to the right site and provider from the first tap.
The demographics your front desk would otherwise retype off paper.
Completed at home, where people actually remember their medications.
Requested up front rather than chased after the first visit.
Captured and timestamped, so it is not a signature nobody can find later.
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. The practice is required by law to maintain the privacy of your protected health information, to provide you with this notice of its legal duties and privacy practices, and to notify you following a breach of unsecured protected health information. Your information may be used for treatment, payment, and health care operations without additional authorization.
Recorded against the submission rather than filed separately.
So the callback is a booking rather than a game of phone tag.
Seven steps, done before the patient arrives. No app, no account, no clipboard in the waiting room.
The part that actually matters
A form that lands in an inbox is a form nobody reads on a busy week. What the patient just filled out goes into a queue that counts how long it has been sitting, and turns red when the answer is too long.
See the staff queue, or read the full case on Patient Intake.
We will look at how intake reaches your front desk today and how long submissions actually sit before someone calls.