A telemedicine e-visit request form is used by patients to submit requests for e-visits from their telehealth providers. If you provide telemedicine services, this free Telemedicine E-visit Request Form makes it easier for you to accept and organize online requests for virtual appointments. To get started, just customize the form to meet your needs and embed it on your website or send the form link via email or message. Patients can provide their personal information, select whether they’d like a phone, email, or video appointment, describe their medical history and insurance details, read your terms and conditions, and complete the form with their electronic signature.Submissions will be stored in your secure Jotform account, protected by HIPAA compliance if you have a Silver or Gold plan — but if you’re offering telemedicine services in response to the COVID-19 outbreak, you can get HIPAA compliance for free with our Coronavirus Responder Program. Since no two telehealth providers are the same, use our drag-and-drop Form Builder to customize this Telemedicine E-visit Request Form for your practice. Add form fields, change the terms and conditions, and integrate the form with other apps you rely on — such as your cloud storage accounts or healthcare CRM — to automatically sync submissions data to those accounts. You can even add a dropdown calendar that lets patients enter dates for their appointments and add them as events to Google Calendar automatically! Schedule and monitor e-visits more easily with our Telemedicine E-visit Request Form and get patients the care they need as quickly as possible.
The New Patient Enrollment Form which personal information, contact information, emergency contact people area and medical history information are provided allows you to have an easier and faster registration process.
A coronavirus screening form is used by healthcare organizations to see what coronavirus symptoms their patients are showing, either to diagnose them with COVID-19 or for contact tracing purposes. Whether you work for an in-person doctor’s office or are collecting information remotely for telemedicine, use this free Coronavirus Screening Form to better understand the symptoms of your patients. Just customize the form to match your practice, then embed it in your website or share it with patients directly to have them fill it out on their computer, tablet, or smartphone. Responses are stored securely in your Jotform account, protected with HIPAA compliance if you upgrade or for free if you apply for our Coronavirus Responder Program.This Coronavirus Screening Form template already has fields for contact information, symptoms, and contact tracing purposes — but if you’d like to add extra questions or make the design match your practice by adding your logo or changing colors, do it in a couple of clicks with our drag-and-drop Form Builder. Instantly send submissions to your other accounts too — like Google Drive, Dropbox, Box, and more — with our 100+ free form integrations. By tracking the symptoms of your patients with a custom Coronavirus Screening Form, you can take steps to diagnose patients with COVID-19 and prevent it from spreading.
A telehealth consent form is used to gather informed consent from patients agreeing to telehealth services. If you offer medical treatments and appointments remotely, this free Telehealth Consent Form will make it easier to accept consenting signatures from patients online. Just customize the form to meet your needs and send it to patients via email or message to get started! You’ll receive submissions safe and sound in your secure Jotform account, protected by HIPAA compliance if you have a Silver or Gold plan — but if you’re offering telehealth services in response to the COVID-19 outbreak, you can get HIPAA compliance for free through our Coronavirus Responder Program.Since every treatment is different, you can customize your Telehealth Consent Form for each patient using our Form Builder. Simply drag and drop form fields and your terms and conditions to inform patients about treatment details, expectations, and their rights. You can even integrate the form with other apps you rely on to automatically sync submissions to those accounts. Use a custom Telehealth Consent Form to keep patients informed before they start receiving care and treatment online.
These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.
Telehealth forms help healthcare practices schedule virtual appointments with patients and collect medical records, informed consent, fee payments, and other important health data online. Whether you’re part of a doctor’s office, teletherapy practice, or dermatology center, you can use Jotform’s free telemedicine forms to securely gather important patient information and diagnose conditions through your website. Simply choose a readymade form template from the list below, customize it to match your practice by adding your logo and updating form fields, then embed it in your website or share it via email to start collecting info online.
To keep sensitive health data protected, be sure to sign up for HIPAA compliance by signing a Business Associate Agreement (BAA) — or if you’re switching to telehealth because of the COVID-19 pandemic, apply for a free unlimited HIPAA account through our Coronavirus Responder Program. You can even automatically send form submissions to other platforms you’re already using, like Google Calendar, Dropbox, Google Drive, and more. Jotform offers an all-in-one solution to collect important info from your patients online — so take your telemedicine practice to the next level with our free Telehealth Forms.
New Patient Enrollment Form which personal information, contact information, emergency contact people area and medical history information are provided; allowing you to have an easier and faster registration process.
Get informed consent from patients online. Collect legally binding electronic signatures. Easy to customize for your practice. HIPAA compliance option.
Get consenting e-signatures online from your patients. Add terms and conditions without coding. Free HIPAA compliance option for coronavirus responders.
HIPAA Medical History Form allows gathering patient's contact details with their current symptoms, medications, allergies, drug use, and family medical history that allows for a better healthcare service and management process.
Collect informed patient consent and e-signatures online with a free Teletherapy Consent Form. Great for remote medical services. Get HIPAA compliance today.
Easy appointment scheduling for e-visits. Great for telemedicine! HIPAA compliance option. Embed anywhere. Integrate with 100+ apps. No coding required.
Refer patients to other physicians and collect referrals online. Easy to customize and embed. Integrate with 100+ apps. HIPAA compliance option. No coding.
Assess the medical condition and health status of the patient online by using this Telehealth Clinical Assessment Form. This form template is simple, clean, and easy to use.
Collect informed consent and e-signatures from patients with a free Sample Telemedicine Consent form. Easy to customize, embed, and share. HIPAA option.
Offering virtual physical therapy appointments? Collect signatures and payments from patients online. Easy to customize and integrate. HIPAA compliance option.
Collect signed patient consent forms online with our free Mental Telehealth Informed Consent Form. Easy to customize and embed. Opt for HIPAA compliance.
Collect medical volunteer registrations online with our free Medical Volunteer Application Form. Easy to customize and embed. Ideal for emergency response.
Survivors can apply to be blood donors through this online plasma donation form. Easy to customize, embed, and integrate. No coding. HIPAA compliance option.
Get informed consent from patients for your telehealth services. Easy to customize and embed. Collect digital signatures. Integrate with 100+ apps. No coding.
This COVID-19 Contact Investigation Form form should be used to interview exposed contacts of confirmed cases. The form provides you with the interview scripts together with all the fields to be filled out regarding the patient and contact.
Telehealth Intake and Signature Form helps your healthcare organization to get patient information and consent to participate in telehealth consultation with signatures.
These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.
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