formisoft
← Back to Templates

Healthcare Form Templates

Page 6 of 11 (328 templates)

Pediatric Sedation Consent Form
Child's Name
Date of Birth
Child's Weight (kg)
Procedure Requiring Sedation
Sedation Level & Agent
Select...
NPO Fasting Status Verified
Allergy & Airway Assessment
Sedation Risks Acknowledged
Submit
Consent

Pediatric Sedation Consent Form

Informed consent for pediatric procedural sedation covering sedation level, agent selection, NPO status verification, monitoring plan, and parent/guardian authorization. For pediatric procedures, imaging, and dental sedation.

2 pages•14 fields•HIPAA-ready
Use template
Photo & Video Consent Form
Patient Name
Date of Birth
Date of Consent
Provider / Photographer Name
Body Area to be Photographed
Purpose of Photography/Video
Usage Authorization (Medical/Education/Marketing)
Storage & Retention Acknowledgment
Submit
Consent

Photo & Video Consent Form

Authorization for clinical photography and video recording. Covers purpose of documentation, usage rights, storage and retention, and patient right to revoke consent. For medical documentation and marketing.

2 pages•10 fields•HIPAA-ready
Use template
Patient Full Name
Date of Birth
Referring Physician
Primary Condition or Diagnosis
Treatment Techniques Authorized
Risks of Physical Therapy Acknowledged
Home Exercise Program Commitment
Modalities Consent (e.g., E-Stim, Ultrasound)
Sign
Submit
Consent

Physical Therapy Consent Form

A consent form for physical therapy and rehabilitation services, covering treatment techniques, exercise programs, and patient participation expectations.

2 pages•11 fields•HIPAA-ready
Use template
Patient Name
Cancer Diagnosis & Treatment Site
Radiation Modality
Select...
Prescribed Dose & Fractionation
Acute Toxicity Risks Acknowledged
Late Toxicity Risks Acknowledged
Fertility Preservation Discussion
Concurrent Chemotherapy Risks
Submit
Consent

Radiation Therapy Consent Form

Informed consent for radiation therapy covering treatment modality, fractionation schedule, acute and late toxicities, fertility preservation discussion, and simulation procedures. For radiation oncology departments and cancer centers.

2 pages•14 fields•HIPAA-ready
Use template
Patient Name
Date of Birth
Ordering Provider
Imaging Study Ordered
Reason for Exam
Contrast Agent Required
Prior Contrast Reaction History
Kidney Function Concerns
Submit
Consent

Radiology & Imaging Consent

Informed consent for diagnostic imaging procedures including CT scans, MRI with contrast, fluoroscopy, and interventional radiology. Covers radiation exposure, contrast agent risks, and pregnancy screening.

2 pages•15 fields•HIPAA-ready
Use template
Research & Clinical Trial Consent
Participant Name
Date of Birth
Study Title & Description
Study ID / Protocol Number
Principal Investigator Name
Expected Duration of Participation
Emergency Contact
Research Participation Consent
Sign
Submit
Consent

Research & Clinical Trial Consent

Informed consent for research participation covering study description, risks/benefits, voluntary participation, data use, and right to withdraw. Compliant with IRB and FDA requirements.

3 pages•12 fields•HIPAA-ready
Use template
Patient Full Name
Date of Birth
Treatment Type & Biologic Product
Select...
Target Anatomy / Treatment Area
Diagnosis & Clinical Indication
Risks & Complications Acknowledged
Contraindication Screening
Current Medications
+
Add
Submit
Consent

Stem Cell & Regenerative Medicine Consent Form

Stem cell therapy consent form for regenerative medicine clinics offering stem cell injections, PRP therapy, and biologic treatments. Covers treatment details, risks and benefits, contraindications, photo documentation, payment, and informed consent.

3 pages•14 fields•HIPAA-ready
Use template
Patient Full Name
Date of Birth
Treatment Program Type
Select...
Substances of Concern
Medication-Assisted Treatment Consent
Drug Testing Policy Acknowledged
42 CFR Part 2 Confidentiality Acknowledged
Emergency Contact Name
Submit
Consent

Substance Abuse Treatment Consent Form

A specialized consent form for substance abuse and addiction treatment programs, addressing 42 CFR Part 2 confidentiality protections and treatment modalities.

3 pages•12 fields•HIPAA-ready
Use template
Surgical Consent Form
Patient Name
Date of Birth
Procedure Date
Procedure Description
Procedure Site & Laterality
Surgeon / Provider Name
Risks & Complications Acknowledgment
Alternative Treatments Considered
Submit
Consent

Surgical Consent Form

Informed consent for surgical procedures including procedure description, risk acknowledgment, anesthesia consent, and e-signature capture. Required documentation for pre-operative workflows.

2 pages•12 fields•HIPAA-ready
Use template
Patient Full Name
Date of Birth
Tattoo Location & Size
Ink Colors Present
Fitzpatrick Skin Type
Select...
Prior Removal Attempts
Medical History & Contraindications
Pre-Treatment Photo Documentation
Take photo
Submit
Consent

Tattoo Removal Consent Form

Tattoo removal consent form for laser tattoo removal clinics and dermatology practices. Covers treatment area documentation, skin type assessment, photo authorization, risks acknowledgment, payment collection, and informed consent for laser procedures.

2 pages•12 fields•HIPAA-ready
Use template
Telehealth Consent for Minors Form
Minor Patient Full Name
Patient Date of Birth
Parent or Guardian Full Name
Guardian Phone Number
Guardian Email Address
Patient Location During Visit
Technology and Privacy Risks Acknowledged
Limitations of Telehealth Acknowledged
Submit
Consent

Telehealth Consent for Minors Form

A parental or guardian consent form for providing telehealth services to minor patients, covering technology requirements, privacy considerations, and limitations of virtual care.

3 pages•12 fields•HIPAA-ready
Use template
Telehealth Consent Form
Patient Name
Date of Birth
Phone Number
Current Physical Location
Technology Requirements Acknowledgment
Sign
Telehealth Limitations Acknowledgment
Sign
Privacy & Recording Consent
Sign
Telehealth Consent & Authorization
Sign
Submit
Consent

Telehealth Consent Form

Consent for telehealth and virtual visit services. Covers technology requirements, privacy expectations, emergency protocols, and authorization for remote healthcare delivery.

1 page•10 fields•HIPAA-ready
Use template
Vaccination Consent Form
Patient Full Name
Date of Birth
Vaccine(s) Requested
Allergies to Vaccine Components
Currently Pregnant or Immunocompromised
Recent Illness or Fever
Previous Adverse Reaction to Vaccines
VIS Received and Reviewed
Submit
Consent

Vaccination Consent Form

A consent form for vaccine administration that captures patient screening questions, vaccine information acknowledgment, and authorization to immunize.

2 pages•12 fields•HIPAA-ready
Use template
ACE (Adverse Childhood Experiences) Screening
Patient Name
Date of Birth
Emotional Abuse
Physical Abuse
Sexual Abuse
Emotional Neglect
Physical Neglect
Domestic Violence in Household
Submit
Screening

ACE (Adverse Childhood Experiences) Screening

Standardized Adverse Childhood Experiences (ACE) screening questionnaire assessing 10 categories of childhood adversity. Used to identify trauma history and inform trauma-informed care approaches.

2 pages•14 fields•HIPAA-ready
Use template
Audiology Hearing Screening Form
Patient Name
Date of Birth
Primary Hearing Concern
Which Ear is Affected?
Duration of Symptoms
Select...
Tinnitus Present?
Noise Exposure History
Dizziness or Balance Issues?
Submit
Screening

Audiology Hearing Screening Form

Comprehensive hearing screening form for audiology practices. Captures patient hearing concerns, tinnitus symptoms, noise exposure history, and baseline audiometric assessment to prepare for diagnostic testing and hearing aid evaluation.

3 pages•10 fields•HIPAA-ready
Use template
Patient Name
Date of Screening
Drinking Frequency
Typical Drinks Per Session
Binge Drinking Frequency
Unable to Stop Drinking
Failed Expectations Due to Drinking
Morning Drinking
Submit
Screening

AUDIT Alcohol Screening Form

WHO Alcohol Use Disorders Identification Test (AUDIT) screening form to identify hazardous drinking, harmful alcohol use, and potential alcohol dependence in patients.

1 page•12 fields•HIPAA-ready
Use template
Child's Name
Date of Birth
Child's Age (months)
Parent/Guardian Name
Points to Show Interest
Interest in Other Children
Responds to Name
Makes Eye Contact
Submit
Screening

Autism M-CHAT Screening Form

Modified Checklist for Autism in Toddlers (M-CHAT) screening form for early detection of autism spectrum disorder in children aged 16 to 30 months.

2 pages•14 fields•HIPAA-ready
Use template
Blood Pressure Log Form
Patient Name
Date and Time of Reading
Systolic Pressure (mmHg)
Diastolic Pressure (mmHg)
Heart Rate (bpm)
Measurement Arm
Select...
BP Classification
Select...
Symptoms or Notes
Submit
Screening

Blood Pressure Log Form

Structured blood pressure monitoring log for tracking systolic and diastolic readings, heart rate, and symptoms across multiple measurement sessions.

2 pages•10 fields•HIPAA-ready
Use template
BMI & Body Composition Form
Patient Name
Date of Measurement
Weight (lbs/kg)
Height (in/cm)
BMI recording
BMI Classification
Select...
Waist Circumference
Body Fat Percentage
Submit
Screening

BMI & Body Composition Form

BMI calculation and body composition tracking form for monitoring weight status, waist circumference, and body fat percentage across patient visits.

1 page•10 fields•HIPAA-ready
Use template
Patient Name
Date of Birth
Date of Screening
Have you felt you should Cut down on drinking?
Have people Annoyed you by criticizing your drinking?
Have you felt Guilty about your drinking?
Have you had a morning Eye-opener drink?
Current Drinking Frequency
Select...
Submit
Screening

CAGE Alcohol Screening Questionnaire

Classic four-question CAGE alcohol screening tool for rapid identification of potential alcohol use disorders. Simple, validated instrument widely used in primary care and emergency settings.

1 page•12 fields•HIPAA-ready
Use template
Employee Full Name
Date of Birth
Email Address
Employer & Department
Biometric Measurements
Blood Pressure & Heart Rate
Lifestyle & Health Habits Assessment
Tobacco, Alcohol & Substance Use
Submit
Screening

Corporate Wellness Screening Form

Corporate wellness screening form for employers, occupational health providers, and workplace wellness programs. Captures employee demographics, biometric measurements, health risk factors, lifestyle assessment, medical conditions checklist, and participation consent.

2 pages•12 fields•HIPAA-ready
Use template
Patient Name
Date of Birth
Age
Alcohol Use in Past 12 Months
Cannabis Use in Past 12 Months
Other Substance Use in Past 12 Months
Ridden in a Car with impaired driver?
Used substances to Relax?
Submit
Screening

CRAFFT Adolescent Substance Abuse Screening

CRAFFT 2.1 screening tool designed for adolescents aged 12-21 to identify substance use risks including alcohol, cannabis, and other drugs. Validated brief screening instrument recommended by the AAP.

2 pages•14 fields•HIPAA-ready
Use template
Patient Name
Date of Screening
Used drugs other than for medical reasons?
Abused prescription drugs?
Able to stop using drugs when you want?
Blackouts or flashbacks from drug use?
Feel guilty about drug use?
Spouse or parents complain about drug use?
Submit
Screening

DAST-10 Drug Abuse Screening

Drug Abuse Screening Test (DAST-10) for rapid identification of drug use disorders. Ten validated yes/no questions assessing drug-related problems, consequences, and loss of control over the past 12 months.

1 page•12 fields•HIPAA-ready
Use template
Patient Name
Date of Screening
Used drugs other than for medical reasons?
Abused prescription drugs?
Able to stop using drugs when you want?
Blackouts or flashbacks from drug use?
Feel guilty about drug use?
Spouse or family complains about drug use?
Submit
Screening

DAST-10 Drug Abuse Screening Test

DAST-10 Drug Abuse Screening Test for identifying drug use problems in clinical settings. Ten validated yes/no questions with structured scoring and severity-level classification.

1 page•14 fields•HIPAA-ready
Use template
Patient Name
Date of Birth
Current Weight & Height
Weight History
Dieting & Food Preoccupation
Binge Eating Behavior
Purging & Compensatory Behaviors
Exercise Patterns
Submit
Screening

Eating Disorder Screening Form

Eating disorder screening form based on EAT-26 style validated questions for identifying anorexia, bulimia, binge eating, and disordered eating patterns. Includes weight history, body image assessment, dietary pattern evaluation, and emergency contact collection.

2 pages•13 fields•HIPAA-ready
Use template
Patient Name
Date of Screening
Baby's Date of Birth
Able to Laugh and See Funny Side
Looked Forward to Things with Enjoyment
Blamed Self Unnecessarily
Anxious or Worried for No Good Reason
Felt Scared or Panicky
Submit
Screening

Edinburgh Postnatal Depression Scale Form

Edinburgh Postnatal Depression Scale (EPDS) screening form for identifying postnatal and postpartum depression in new mothers during the perinatal period.

1 page•12 fields•HIPAA-ready
Use template
Epworth Sleepiness Scale
Patient Name
Date of Birth
Sitting and Reading
Watching Television
Sitting Inactive in a Public Place
As a Passenger in a Car for an Hour
Lying Down to Rest in Afternoon
Sitting and Talking to Someone
Submit
Screening

Epworth Sleepiness Scale

Epworth Sleepiness Scale (ESS) questionnaire measuring daytime sleepiness across eight common situations. Validated screening tool for identifying excessive sleepiness and potential sleep disorders.

1 page•12 fields•HIPAA-ready
Use template
Fall Risk Screening Form
Full Name
Fall History (Past 12 Months)
Select...
Fall Circumstances & Injuries
Current Medications (Count)
High-Risk Medications
+
Add
Balance & Mobility Confidence
Vision Concerns
Home Environmental Hazards
Submit
Screening

Fall Risk Screening Form

Fall risk assessment for older adults covering fall history, medication review, mobility assessment, environmental hazards, and fear of falling. Based on CDC STEADI protocol for fall prevention.

2 pages•10 fields•HIPAA-ready
Use template
Patient Name
Date of Evaluation
Referring Provider
Job Title / Occupation
Lifting Capacity (Floor to Waist)
Carrying Tolerance
Standing Tolerance (minutes)
Walking Tolerance (minutes)
Submit
Screening

Functional Capacity Evaluation Form

Functional Capacity Evaluation (FCE) form for assessing a patient's physical functional abilities, work capacity, and activity tolerance for disability and return-to-work determinations.

3 pages•16 fields•HIPAA-ready
Use template
GAD-7 Anxiety Screening
Full Name
Feeling nervous, anxious, or on edge
Not being able to stop worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid something awful might happen
Submit
Screening

GAD-7 Anxiety Screening

Standardized GAD-7 anxiety screening questionnaire with structured scoring, severity levels, and clinical guidance. Validated tool for generalized anxiety disorder screening in clinical settings.

2 pages•10 fields•HIPAA-ready
Use template