Virtual Health Evaluation Form Template

Quickly and securely gather vital patient information through this easy to use and HIPAA-compliant Virtual Health Evaluation Form Template from Formsite. Healthcare providers in every setting, from face to face primary care settings to virtual care settings, understand the ongoing importance of proper patient data collection, storage, and access. This sample telehealth services patient intake form can help with all of that.

Whether due to the COVID-19 pandemic or the lack of rural health access in rural areas, it’s increasingly common for virtual healthcare to make up at least some portion of patient care. This virtual health questionnaire gathers pertinent information during the patient intake process like patient name, address, current health insurance, Medicaid, or Medicare information, patient health history, current medications, vaccinations, health concerns, inpatient history, and more. There’s even disclaimer language at the end of the form that can be edited to fit your specific health care system or health care services setting.

All Formsite forms, including this one, are easy to customize with our drag and drop editor. Once complete, simply embed this form in your website, or email it or share it with new patients on social media with no knowledge of coding necessary. All Formsite form data is encrypted when submitted and while stored, and this form, like all Formsite healthcare forms, is HIPAA-compliant.

Try the sample tele patient intake form below.