Intake Form (Child)
Use this secure healthcare intake form to collect key information about children before their first appointment. Completed by a parent or guardian, it helps you prepare in advance and show families you take privacy seriously. Send it as a secure link or include it in a welcome packet — all client data is encrypted the moment it’s submitted.
Form Template Preview
Submit this form to see what a completed submission looks like inside Hushmail:
Quick facts about this form
Who it's for:
- Healthcare practices
- Behavioral health providers
- Physical therapy clinics
- Chiropractic practices
- Massage therapy practices
- Dental practices
- Nutrition professionals
- Holistic care providers
Why use it:
- Collect key information in advance to tailor care from the start
- Protect privacy with automatic encryption and HIPAA-compliant data handling
- Save time and reduce compliance risks by replacing paperwork
- Make a good impression with a seamless intake process
Where to use it:
- In an email to parents or guardians
- In a “New Patients” section on your website
- On your booking confirmation page
If your client skips a required field, the form will prompt them to fill it out. No more chasing after clients to fill out missing info.
Your client’s submission will live in Hushmail, where you can keep all submissions secure and organized in folders.
You can also download a PDF of the submission if you want to file a separate copy elsewhere, like your EHR.
-
1.
You give us the form(s) you’re currently using in your practice.
-
2.
You get a dedicated Customer Care rep to oversee the service and answer questions.
-
3.
You end up with custom secure web forms that are easy for your clients to fill out.
