Healthcare Form Templates
Medical forms need extra care: sensitive data, detailed questions, follow-ups that depend on earlier answers, uploads for insurance cards and previous records, and consent. Fillin Forge ships 6 healthcare form templates. They hold the questions only: none of them has a file upload field or conditional logic rules, and only Medical Consent has a consent checkbox. You add the rest in the builder.
Healthcare templates
Patient Intake
Patient Name, Date of Birth, Phone, Email, Address, Emergency Contact, Emergency Phone, Current Medical Conditions, Current Medications and Allergies.
Appointment Request
Patient Name, Phone, Email, Visit Type (a dropdown: New Patient, Follow-up, Urgent, Telehealth), Preferred Date, Preferred Time (Morning, Afternoon or Evening) and Reason for Visit.
Health Assessment
Overall health? (Excellent, Good, Fair, Poor), Exercise frequency (a dropdown), Average sleep hours (a slider from 3 to 12), Stress level (1-10) (a slider) and Health concerns.
Medical Consent
Patient Name, Date of Birth, Procedure Name, a block of consent text, a required checkbox (I provide my informed consent) and Date.
Prescription Refill
Patient Name, Date of Birth, Phone, Medication Name, Dosage, Preferred Pharmacy and Additional Notes.
Symptom Checker
Name, Symptoms (checkboxes: Fever, Cough, Headache, Fatigue, Nausea, Pain), Severity (1-10) (a slider), Duration (a dropdown) and Additional details.
Important notes for healthcare providers
HIPAA and compliance
Fillin Forge is a WordPress plugin. It stores submissions in the database of your WordPress site. It does not make a site follow the HIPAA rules, and we do not claim that it does. What those rules ask of a site depends on its hosting, the agreements you hold with the providers involved, and how the site is set up.
What Fillin Forge does and does not do with this data:
- Submissions are stored in your WordPress database. The values are saved as plain text, which Fillin Forge does not encrypt, together with the visitor’s IP address and browser user agent
- HTTPS is up to you. Fillin Forge has no setting that forces HTTPS, so serve the whole site over HTTPS yourself
- Capability-based access. The Submissions screen, the CSV export and the PDF download require the manage_options capability, which administrators have by default
- Uploaded files are saved under random names in the formforge-private folder inside your WordPress uploads folder, and Fillin Forge puts an .htaccess file with Deny from all in that folder
- No audit log. Fillin Forge does not record who viewed or deleted a submission
- Third-party scripts on the page with the form. Fillin Forge adds no analytics script. Three features load a script from another company: Google reCAPTCHA v3 (once you enter its keys), Google Maps or Yandex Maps (a map field with a key), and Stripe.js (a Payment field with the Stripe publishable key). In Fillin Forge Pro, the optional Usage analytics (privacy-friendly) setting sends statistics to Avakode from your server; it is off until you switch it on
- Features that send submissions elsewhere. The notification email (Notify admin on submission) carries the field values to the address in Notification email. A Webhook URL posts each submission to the address you enter. The Pro integrations send data from a submission to the service you connect: Slack, Discord, Telegram, WhatsApp, Mailchimp, Google Sheets, Google Calendar and HubSpot CRM
- Which of them pass through our server. The notification email, the webhook, Slack and Discord are sent by your site directly and never reach us. For Telegram, WhatsApp, Mailchimp, HubSpot, Google Sheets and Google Calendar, your site sends the submission data the integration needs to our API (api.avakode.com), and our API passes it on to the service. We relay this data and do not store its content. The Privacy Policy lists what is sent for each one
- PDF download of a submission. On a site with Fillin Forge Pro, the fields of that submission are sent to our API (the Forge API, api.avakode.com), which builds the PDF and sends it back; if our API cannot be reached, the PDF is built on your site. We relay this data and do not store its content
Ask your compliance officer what the HIPAA rules require of your hosting, your agreements and your site setup.
Consent fields
Only the Medical Consent template has a consent field: a required checkbox (I provide my informed consent) under a block of consent text. The other five healthcare templates have none, so add a Checkbox field where your privacy rules ask for consent.
Signatures
Fillin Forge has no signature field. The Medical Consent template uses a required checkbox and a Date field.
Conditional logic for medical follow-ups
None of the healthcare templates comes with conditional logic rules, because a template carries only its fields. You add the rules in the builder. Examples of rules you could add:
- “Are you currently taking any medications?” → if Yes, show a Textarea field to list them
- “Any known allergies?” → if Yes, show severity and reaction fields
- “Previous surgeries?” → if Yes, show a Text field for the surgery type and a Date field
- “Pregnant or breastfeeding?” → if Yes, show pregnancy-specific questions
- “Blood pressure medication?” → if Yes, show current BP reading field
Keeps the form short for healthy patients and thorough for patients with complex histories.
File uploads for insurance and records
None of the six healthcare templates has a file upload field. If you need insurance card photos, previous records or referral letters, add a File Upload field to the form in the builder.
Uploads are stored under random file names in a private folder inside the uploads folder, with an .htaccess rule that blocks direct access on servers that read .htaccess. Only users with the right permissions can access them from the WordPress admin.
Ready to digitize your intake process?
Healthcare templates are included in every version of Fillin Forge. Consult your compliance officer about full HIPAA requirements for your infrastructure.