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Podiatry intake form
38 reviews
130K+
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Use our readymade template to create this Google form. Customize it further using our form builder.

Create your intake form

Assessment form builder
  • navigate_next Use prebuilt template to create a HIPAA compliant online podiatry intake form
  • navigate_next Collect patient, demography, emergency contact details, medical history
  • navigate_next Collect foot-related concerns, pain level, and lifestyle impact
  • navigate_next Allow patients to upload their driver’s id, prescriptions for medications
  • navigate_next Get signatures for consent for treatment, notice of privacy practices, use of PHI

Collect responses from your patients

Patient ID user input
Patient Name user input
Patient Email user input
Patient Phone Number user input
Marital Status user input
Date of birth user input
Address user input
Emergency Contact Name user input
Emergency Contact Phone user input
Relationship user input
Primary Doctor user input
Location user input
Date of service user input
Primary Insured (subscriber) user input
Relationship to Patient user input
Date of Birth user input
Phone number user input
Subscriber Employer or Plan Sponsor user input
Insurance Company user input
Subscriber ID# user input
Secondary Policy Holder Name user input
Date of Birth user input
Subscriber Employer or Plan Sponsor user input
Phone number user input
Insurance Company user input
What are the medical issues concerning your foot, ankle and legs? user input
Result of accident or work injury? No
On a scale of 1-10, what is your level of pain? user input
Pain Type: user input
Since the time your pain or problem began, has it: user input
How has this problem affected your lifestyle or ability to work? user input
Have you visited a podiatrist before? user input
Name of the podiatrist user input
Last appointment date user input
Are you a diabetic? No
What athletic activities do you participate in and how often? user input
Do you get leg cramps after activity? No
Does foot pain limit your desired activities? user input
Do you have any difficult walking? user input
Any pain in the calves or buttocks when walking? user input
Which of these foot problems do you have or had in the past? Corns/Calluses,Fungal Toenails
Are you currently experiencing any of the following symptoms? Fever,Muscle aches
Are you currently in good health? Yes
Are you under the care of a physician? No
Have you or any family member had or currently have any of these medical conditions: High Blood Pressure,Diabetes
Have you had any serious illness/operation/ or been hospitalized? No
Are you currently taking any medications? No
Upload prescriptions user input
Do you have any allergies? user input
List any allergies you may have user input
Do you use, or have you in the past, used any of the following products: Tobacco,Alcohol
Smoking Status Never smoked
Alcohol Intake None
Are you or could you be pregnant/nursing? No
  • navigate_next Pre-populate patient details from your booking system to reduce errors
  • navigate_next Send an email invitation with a secure link for patients to complete their intake
  • navigate_next Allow patients to save their progress and complete their form at a later time
  • navigate_next Set up an email template and send invitation emails to multiple patients with ease
  • navigate_next Send an email to the patients with a copy of their response when they submit the form

Track patient responses in Google Sheets

Assessment form builder
  • navigate_next Export patient responses to Google Sheets for easy record-keeping
  • navigate_next Create a custom workflow and manage your patient intake efficiently
  • navigate_next Use pre-built reports to easily keep track of patient progress over time
  • navigate_next Receive a copy of the response by email when a patient submits the intake form
  • navigate_next Use data in Google Sheets to integrate with EHR systems for seamless data transfer

HIPAA compliance

Patient ID: ******
Patient Name: ******
Patient Email: ******
Patient Phone Number: ******
Marital Status: user input
Date of birth:11/30/1899
Address:user input
Emergency Contact Name: user input
Emergency Contact Phone: user input
Relationship: user input
Primary Doctor: user input
Location: user input
Date of service:11/30/1899
Primary Insured (subscriber) : user input
Relationship to Patient: user input
Date of Birth:11/30/1899
Phone number: user input
Subscriber Employer or Plan Sponsor: user input
Insurance Company: user input
Subscriber ID#: user input
Secondary Policy Holder Name: user input
Date of Birth:11/30/1899
Subscriber Employer or Plan Sponsor:11/30/1899
Phone number: user input
Insurance Company:11/30/1899
What are the medical issues concerning your foot, ankle and legs?:user input
Result of accident or work injury?: No
On a scale of 1-10, what is your level of pain?: 0
Pain Type:: user input
Since the time your pain or problem began, has it:: user input
How has this problem affected your lifestyle or ability to work?:user input
Have you visited a podiatrist before?: user input
Name of the podiatrist: user input
Last appointment date:11/30/1899
Are you a diabetic?: No
What athletic activities do you participate in and how often?:user input
Do you get leg cramps after activity?: No
Does foot pain limit your desired activities?: user input
Do you have any difficult walking?: user input
Any pain in the calves or buttocks when walking?: user input
Which of these foot problems do you have or had in the past?: Corns/Calluses, Fungal Toenails
Are you currently experiencing any of the following symptoms?: Fever, Muscle aches
Are you currently in good health?: Yes
Are you under the care of a physician?: No
Have you or any family member had or currently have any of these medical conditions:: High Blood Pressure, Diabetes
Have you had any serious illness/operation/ or been hospitalized?: No
Are you currently taking any medications?: No
Upload prescriptions: user input
Do you have any allergies? : user input
List any allergies you may have:user input
Do you use, or have you in the past, used any of the following products:: Tobacco, Alcohol
Smoking Status: Never smoked
Alcohol Intake: None
Are you or could you be pregnant/nursing?: No
  • navigate_next Create a HIPAA compliant intake form to safely collect, store and access patient responses
  • navigate_next Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
  • navigate_next Mask PHI fields when exporting form responses to Google Sheets and sending them on email
  • navigate_next Pre-populate patient details in intake forms by creating secure prefill links without exposing PHI
  • navigate_next Limit access to patient data only for authorized personnel and minimize risk of data breaches

These reviews are reproduced without modification from Google Workspace Marketplace.

April 22, 2026

4 stars

We chose Formesign to create and collect information for incoming requests for our services. We needed to capture details of client requests and get their signatures to communicate further and provide support. The product is very adaptable, but requires a fair amount of support for a client like me who isn't tech savvy. Vipin has been extremely helpful in getting us more knowledgeable with this product. We're still learning, and appreciate the tech support we continue to receive.

— Karen Newberry

April 28, 2026

Thanks for the feedback, Karen! Vipin shared the friction you've hit with Drive setup and consent text editing and both are on our list to make smoother. Glad he's been able to help in the meantime. Please reach out anytime you're stuck on something.

— Mani Doraisamy

April 5, 2026

5 stars

I decided to use Formesign to help me leverage HIPAA-compliant forms for my practice website. What attracted me to use them was the design/flow of the product and the price point. I had done a good bit of research on what was out there, and as someone with a small business, I wanted to get the best bang for my buck. So far, I have been incredibly pleased with the product and how I have been able to integrate my forms into my website. Customer support and setup has been great. I have zero complaints at this time and would absolutely recommend going with Formesign if you may be in a similar situation to my own (small private practice in need of HIPAA compliant forms with a pleasing interface).

— Griffin Chapple

March 17, 2026

5 stars

We are currently using Formesign for a non-profit academic research project on Chinese language teaching at the University of Queensland. We chose Formesign because it integrates smoothly with Google Forms and makes it easy to manage consent forms and research documentation within the same workflow. The features we found most valuable are the simple e-signature process, seamless Google Workspace integration, and ease of use for participants. This has made it much easier for us to collect and manage signed documents during our questionnaire survey process. So far our experience with the add-on has been very positive. It is straightforward to set up, reliable, and works well within the Google ecosystem, which is essential for academic research teams that rely heavily on Google tools. Overall, Formesign has been a practical and efficient solution for our research data collection process.

— Yao Li

March 6, 2026

5 stars

This product is exactly what we were looking for. It builds on a familiar tool (Google Forms), integrates seamlessly with the Google products, and adds much needs features for managing signed documents. We had tried using Adobe Acrobat forms tool and found it to be really lacking in features, especially the need for readable responsive design for mobile devices. While there is a learning curve, it is well worth it, and the personalized, live support is exceptional in an age where you normally have to play 20 questions with a chatbot. I worked with Vipin via Google Meet and screen sharing, and he was exceptionally helpful and patient and even provided additional tips on improving the appearance of the form I had designed. Bottom line - very pleased!

— Monty Morée

February 25, 2026

5 stars

Formesign Formesign had a truly transformative impact on my operations. The forms, signature process, and overall system they delivered are flawless. Everything works together intuitively, creating a level of efficiency and professionalism that has significantly elevated my business operations. Beyond the technical excellence of their work, what truly sets them apart is their commitment to customer service. Their one-on-one support was exceptional—courteous, responsive, and consistently focused on understanding and meeting my specific business needs. Vipin was my contact person. He was always available, patient, and thorough, ensuring that every detail was perfectly coordinated. I highly recommend Formesign to any organization looking to improve efficiency, accuracy, and workflow through customized systems. Their expertise, combined with their dedication to client satisfaction, makes them an outstanding partner.

— Mike Balducci

May 4, 2026

5 stars

We are using Formesign for two of our signature workflows. We had assistance throughout the implementation process that surpassed our expectations. Formesign signature workflow now makes sure we get employee performance reviews and warning documentation forms signed by team member and their manager and allows for a supervisor approval along the way.

— Matt West

November 1, 2025

5 stars

I chose Formesign because I needed a solution to link forms with signature capabilities. We are in the home service business and have a very large fleet of field operators. Formesign ability to link forms and gather signatures has removed the intense manual collection of this process out of our operation. Specifically, Vipin on the support side of Formesign has been valuable in advising on flow and making sure the process is lean. Formesign is...plug and play. Thank you!

— Jason Crossen

May 30, 2025

1 stars

Besides the fact that one gets billed $216 monthly, Support took a long time to try and get things to work. Trying to get things signed on a form was such an issue and through out formatting. Way over priced, support that you have to wait till the next day to get one thing sorted and not sorted, back and forth the whole time. Frustrating customers and damage to business. I will not reccommend this company to anyone. Try JotForms so much better, and you can do much more for a fraction of the cost per year not per month.

— Francois Ohsiek

June 3, 2025

Hi Francois, sorry you had a frustrating experience with the formatting. Just to clarify, the plan you’re on is $216 per year, not per month. You signed up for the Formesign Esignature paid plan on May 8, 2024, and since you also needed to sign agreements, we provided access to our Formesign - Fillable PDF add-on at no extra cost. Regarding formatting: when working with Google Docs templates, we recommend using lists instead of indents and setting up layouts with tables for images, rather than inserting images directly. This helps maintain proper formatting. To assist, we also created and shared a sample template as a reference. You had asked us to make edits on your behalf, which we’re not able to do for security reasons. However, we did reach out and invited you to join a scheduled Zoom call to walk through the process — as we’ve done several times over the past year — but we didn’t receive a response. Update: To make things easier for all users, we have just launched the new document editor in Formesign that will allow agreements to be created directly, without relying on Google Docs.

— Formfacade

September 11, 2025

2 stars

The platform is good but promises one week of premium usage based on which I chose it. Once my form was sent out to participants, it capped the responses at 24 and I was forced to pay 36 USD to keep the form active. Really disappointed by the lack of clarity and the overly tight response numbers for each tier of the plan considering how nice the platform could be.

— Nishka Khendry

July 23, 2023

5 stars

I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!

— Sol Evans

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Podiatry Intake forms
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