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

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 21 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 Workers' Compensation 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 Workers' Compensation Intake Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

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