Please complete this form before your telehealth appointment.
Healthcare template · 13 fields (9 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
Set up your telehealth intake form
Please complete this form before your telehealth appointment.
Send the video link and a tech check tip after this is submitted. Use a HIPAA-appropriate setup when collecting health information.
The form separates phone number, date of birth, reason for visit, current medications (optional) into labeled questions. Review the choices and required fields for your organization before sharing it.
Best practices
Send the video link and a tech check tip after this is submitted. Use a HIPAA-appropriate setup when collecting health information.
Customize the phone number and date of birth questions to match your records and terminology.
Name the team that reviews responses and explain what happens after submission. A requested date, service or approval is not automatically confirmed.
Ask only for information needed for this step. Arrange any sensitive supporting documents through an appropriate private process.
Every field, explained
Patient full name (Name, required)
Email address (Email, required)
Phone number (Phone, required)
Date of birth (Date, required)
Reason for visit (Long text, required)
Current medications (optional) (Long text)
Allergies (optional) (Long text)
Preferred pharmacy (optional) (Short text) — Pharmacy name and city or street.
Insurance provider (optional) (Short text)
Where will you be during the visit? (Address, required) — Providers need your location at the time of the visit.
Preferred visit type (Single choice, required)
Emergency contact name and phone (Short text, required) — Name, relationship and phone number.
Confirmation (Multiple choice, required)
Frequently asked questions
What does this telehealth intake form template collect?
Alongside contact details, it asks for phone number, date of birth, reason for visit, current medications (optional), allergies (optional), preferred pharmacy (optional), insurance provider (optional), where will you be during the visit?, preferred visit type, emergency contact name and phone, confirmation. You can rename questions, change choices and remove fields that your workflow does not need.
How should I use this telehealth intake form form?
Send the video link and a tech check tip after this is submitted. Use a HIPAA-appropriate setup when collecting health information.
Can I edit this form and print a copy?
Yes. Open an editable draft, adjust the questions, and review the preview before publishing. You can also use the template page’s print option. Publishing requires an account; the draft can be tried first.