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Home Infusion Therapy Patient Intake Form
Intake

Home Infusion Therapy Patient Intake Form

3 pages•18 fields•HIPAA-ready
Ready to useHIPAA compliantCustomize in minutes
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Home Infusion Therapy Patient Intake Form

Home Infusion Therapy Patient Intake Form

Page 1 of 3

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Primary Diagnosis Requiring Infusion
Type of Infusion Therapy
Select an option...
Current Venous Access Type
Select an option...
Insurance Provider
Insurance carrier & policy
Known Allergies
Refrigeration Available at Home
Option A
Option B
Option C
Submit
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This specialized intake form is designed for home infusion therapy providers, specialty pharmacies, and home healthcare agencies that deliver intravenous medications and treatments in patients' homes. It captures essential clinical information including diagnosis requiring infusion therapy, current venous access type (PICC line, port, peripheral IV), previous infusion experience, detailed allergy history, current medications including anticoagulants, and insurance coverage for home infusion services.

The form includes critical home safety assessments such as refrigeration availability for medication storage, clean space for supplies, electrical outlet access, caregiver availability during infusions, and emergency contact protocols. It also collects pharmacy coordination details, preferred delivery schedules, nursing visit preferences, and documentation of physician orders for home infusion therapy. This ensures safe, efficient setup of home infusion services while meeting regulatory requirements and coordinating care between prescribers, pharmacies, and nursing staff.

What's included

  • Primary diagnosis and infusion indication
  • Type of infusion therapy ordered
  • Venous access device information
  • Previous infusion therapy history
  • Medication and allergy documentation
  • Home environment safety assessment
  • Refrigeration and storage capacity
  • Insurance and prior authorization details
  • Emergency contact and caregiver information
  • Prescriber and referral source information

Who uses this template

  • Home Infusion Pharmacy Companies
  • Home Healthcare Agencies
  • Specialty Pharmacy Providers
  • Hospital-Based Home Infusion Programs
  • Nursing Infusion Services

All form fields

8 fields across 3 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Primary Diagnosis Requiring InfusionText
Type of Infusion TherapyDropdown
Current Venous Access TypeDropdown
Insurance ProviderInsurance Info
Known AllergiesAllergies
Refrigeration Available at HomeMultiple Choice

How to use the Home Infusion Therapy Patient Intake Form

Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Home Infusion Therapy Patient Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.

Setup steps

  1. 1Choose the template. Find the Home Infusion Therapy Patient Intake Form in the template library and click “Use this template” to add it to your account.
  2. 2Customize fields. Add, remove, or reorder any of the 18 fields. Set fields as required or optional based on your practice needs.
  3. 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
  4. 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
  5. 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.

Frequently asked questions

Is the Home Infusion Therapy Patient Intake Form HIPAA compliant?

Yes. All Formisoft templates, including the Home Infusion Therapy Patient Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.

Can I customize the fields in this template?

Absolutely. You can add, remove, reorder, or modify any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

How do patients fill out this form?

Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.

Can I send this form automatically before appointments?

Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.

Does this template work on mobile devices?

Yes. The Home Infusion Therapy Patient Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.

8 min saved per patient98% patient satisfaction3x faster than paper

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