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The Patient Intake Form

This is the form your patients fill out before their visit, using the link from your clinic settings. You can share it by text, email, or a printed QR code. Patients can use any phone, tablet, or computer.

This page shows you what your patients will see, so you can help them if they get stuck.

Choosing a language​

When a patient opens the link, they first pick a language.

The language picker with English and Español buttons

  1. The patient taps the white "English" button or the white "Español" button.
  2. The whole form then appears in that language.

The 7 steps​

After choosing a language, the patient moves through 7 short steps. A row of numbered circles at the top shows their progress: a green check means a step is done, a blue circle is the step they are on, and a gray circle is a step still to come.

The steps are:

  1. Name
  2. Personal Details
  3. Immigration IDs
  4. Home Address
  5. Contact Info
  6. Additional Roles
  7. Review

Step 1: Name​

The Name step of the patient form

  1. The patient types their First Name and Last Name. (Middle Name is optional.)
  2. They click the blue "Continue →" button at the bottom-right.
note

A red star (*) means a box is required. The form will not let the patient continue until every required box is filled in.

Step 2: Personal Details​

The Personal Details step

The patient chooses their Sex (tap Male or Female — the choice turns blue), picks their Date of Birth (Month, Day, and 4-digit Year), and types their City of Birth and Country of Birth.

Steps 3–6: IDs, Address, Contact, and Roles​

  • Immigration IDs — The patient answers whether they have an A-Number or USCIS account number. (Most U.S. citizens do not have these.) If they tap No, the boxes stay hidden.
  • Home Address — Their current U.S. street address, city, state, and ZIP code.
  • Contact Info — A daytime phone number and an email address.
  • Additional Roles — Whether an interpreter helped them, and whether someone else (a preparer) filled the form out for them.

Step 7: Review​

On the last step, the patient checks a summary of everything they typed.

  1. They read it carefully to make sure the name spelling, date of birth, address, and phone number are correct.
  2. To fix something, they click "← Back" to return to an earlier step.
  3. When everything looks right, they click the green "Confirm" button.
  4. They see a "Success!" message.
tip

Tell patients to bring their immunization (shot) records to the appointment. The form reminds them on the last step, but a heads-up helps.

After a patient confirms, their information appears on your Dashboard as a new card.

Next: Your Dashboard →