formisoft

Infectious Disease Intake Form

Asks about referring physician, presenting infection & symptoms, and symptom timeline. Built for general infectious disease consultation practices.

Questions
20
Pages
2
Time
about 5 min

Includes

  • E-signature
  • File upload
  • Insurance details
  • Allergy list
  • Conditions checklist
Use this templatePrint it instead

Your practice

Infectious Disease Intake Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • General infectious disease consultation practices
  • HIV medicine and Ryan White-funded clinics
  • Transplant infectious disease and immunocompromised host programs
  • Travel medicine and tropical disease clinics

What's inside

Page 1 · Your information

  1. Full NameText · Required
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Email AddressEmail
  5. Referring PhysicianText

Page 2 · Additional details

  1. Immune Status EvaluationLong Text
  2. Prior Culture & Sensitivity ResultsLong Text
  3. Current Antimicrobial TherapyLong Text
  4. Antimicrobial Allergy HistoryAllergies
  5. TB Screening HistoryLong Text

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Infectious Disease Intake Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

All templates

Questions

Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.

Yes. You can add, remove, reorder, or reword any of the 20 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Yes. The Infectious Disease Intake Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

Add the Infectious Disease Intake Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

Use this templateBook a demo