Workers' Compensation Intake Form

Asks about employer name, occupation, and employer phone number. Built for occupational medicine clinic intake for workplace injuries.

Questions: 21
Pages: 2
Time: about 5 min

E-signature

Your practice

Page 1 of 2

Full Name

Date of Birth

Email Address

Phone Number

Employer Name

Occupation

Employer Phone Number

Live preview. Tap through it like a patient.

Who it is for

Occupational medicine clinic intake for workplace injuries
Urgent care treatment of on-the-job injuries
Orthopedic evaluation of work-related musculoskeletal injuries
Follow-up documentation for workers' compensation claims

What's inside

Page 1

Full NameText · Required
Date of BirthDate · Required
Email AddressEmail · Required
Phone NumberPhone · Required
Employer NameText · Required
OccupationText · Required
Employer Phone NumberText

Page 2

Date of InjuryDate · Required
Time of InjuryTime · Required
Location Where Injury OccurredText · Required
Describe How the Injury OccurredLong Text · Required
Body Parts InjuredCheckbox · 12 choices · Required
SymptomsCheckbox · 6 choices · Required
Current Pain Level (1-10)Multiple Choice · 10 choices · Required
Was the Injury Reported to Your Employer?Multiple Choice · 2 choices · Required
Workers' Comp Claim NumberText
Workers' Comp Insurance CarrierText
Treating PhysicianText
Previous Workplace InjuriesLong Text
Current MedicationsLong Text
Patient SignatureE-Signature · Required

From form to a ready patient

01
Make it yours
Reword, reorder, or add to the Workers' Compensation 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 21 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 Workers' Compensation Intake Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

Use this template