formisoft

Patient Transfer Request Form

Asks about patient address, current provider / facility, and receiving provider / facility. Built for primary care practices facilitating patient transfers to new physicians.

Questions
14
Pages
2
Time
about 4 min

Includes

  • Consent agreement
  • Insurance details
  • Emergency contact
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Your practice

Patient Transfer Request Form

Page 1 of 2 · Your information

Live preview. Tap through it like a patient.

Who it is for

  • Primary care practices facilitating patient transfers to new physicians
  • Hospital discharge planning departments coordinating post-acute care transitions
  • Specialist offices requesting records from referring providers before initial consultations
  • Multi-location health systems transferring patient care between affiliated facilities

What's inside

Page 1 · Your information

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

Page 2 · Additional details

  1. Records RequestedCheckbox · 6 choices
  2. Transfer Method PreferenceDropdown · 3 choices
  3. Transfer UrgencyLong Text
  4. Insurance InformationInsurance Info
  5. Emergency ContactEmergency Contact

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 Patient Transfer Request 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.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. 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.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Patient Transfer Request Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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