Pediatric Intake Form

Asks about child's full name, parent/guardian full name, and parent/guardian phone number. Built for pediatric practices and children's clinics.

Questions: 10
Page: 1
Time: about 3 min

E-signature

Your practice

Child's Full Name

Date of Birth

Parent/Guardian Full Name

Parent/Guardian Phone Number

Emergency Contact Name

Emergency Contact Phone

Does your child have any allergies?

Is your child up to date on vaccinations?

YesNo

Primary Care Physician

Signature

Live preview. Tap through it like a patient.

Who it is for

Pediatric practices and children's clinics
Family medicine offices seeing children
School-based health clinics
Pediatric specialty referrals

Formisoft for Pediatrics

What's inside

Child's Full NameText · Required
Date of BirthDate · Required
Parent/Guardian Full NameText · Required
Parent/Guardian Phone NumberPhone · Required
Emergency Contact NameText · Required
Emergency Contact PhonePhone · Required
Does your child have any allergies?Long Text
Is your child up to date on vaccinations?Multiple Choice · 2 choices · Required
Primary Care PhysicianText
SignatureE-Signature · Required

From form to a ready patient

01
Make it yours
Reword, reorder, or add to the Pediatric Intake Form, and add your logo.
02
Patients finish it at home
A secure link by text or email, filled out on their phone before the visit. No app.
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 10 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 Pediatric Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

Use this template