Doctor Visit Form Template

Please complete this form before your doctor's visitHi there, what's your name?and your address?What would you like to visit the doctor for?How urgent is this?Do you have any existing conditions or illnesses?

Diabetes

Asthma

Epilepsy

Heart disease

High blood pressure

Are you taking any medication?Please enter the names belowWhat phone number can we reach you on? Thanks! We'll be in touch soon.

Collect up to 3.5x more data with Typeform

A simpler way to keep your records up-to-date

This doctor visit form helps patients request appointments and update their medical records in just a few clicks. And the integrations that come with it manage your data automatically. So patients get a smoother visit, and you get less paperwork.

With Typeform, you can customize everything

Change text, colors, and even logos to match the look and feel of your brand. Then embed forms smoothly onto web and email.

Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.

Stay efficient by connecting forms to your workflow. Typeform integrates with 120+ tools including Slack, Zapier, and HubSpot.

Doctor visit form FAQs:

With Typeform, it couldn't be simpler. Start with our free template and customize it to your heart's content. You can edit the design, colors, and fonts, and even add different questions and images to make it your own.

Plug the form into your most-used apps, so responses arrange themselves as they come in. When the form's finished, click publish, then spread it far and wide. Share the link across social media or embed it into your website, and you're good to go.

This online form—plus the integrations it comes with—helps you get organized. Once you've collected submissions, simply click export and automatically download an organized spreadsheet or CSV file full of form data.

Or you can take your data management up a level with our smart integrations. With these, you can automatically send the data straight to Google Sheets, Trello, Airtable, or one of our other apps. Save tons of copy-paste time and spend more time on things that matter.

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.