Vaccination Request Form
Let patients sign up for vaccination in a minute using a free request form. Gather patients’ contact details, insurance information, and basic medical data through an online form. You can personalize the vaccine request form to gather the information needed for COVID-19, flue, hepatitis, or any other vaccine. Then, embed the form to your website, share it with a link, or have patients fill it out in person on your office’s tablet or computer. You can even convert submissions into PDFs automatically, print it or attach it to electronic medical records.
Structure and logic of the form
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The form sections are visually divided with grid containers. Use grids in a form design to simplify layout, ensure consistency, and enhance the user experience.
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The calendar start view is set up to show the years of the decade. Thus, patients can quickly find the required date by year, then select the month and date without endless scrolling through the calendar.
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To make sure patients are over 18 years old, the dates within the last 18 years are disabled. Specify the available date range in the calendar to efficiently schedule appointments, follow-up consultations, or treatment plans, track vaccination expiry dates, and more.
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The Phone, Medicare Number and Individual Health Identifier (IHI) fields accept only digits to prevent input errors. It's done with Masked Text field type. Use it to specify a particular format and ensure accurate data collection for patient details, including social security numbers, health insurance policy numbers, and medical IDs.
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The email fields only accept data that matches the specified pattern to ensure users enter valid emails. Patterns are an alternative to the Masked Text field to restrict user input. Choose from predefined patterns or create your own to verify patient information.
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When patients answer 'yes' to any question, additional fields appear to collect more details. It's done with a JavaScript function and helps keep the form neat and user-friendly. In the same way, you can deactivate fields, make them mandatory, show or hide containers, change element styling, and more. Find code examples in the Manage fields article.
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Patients must agree to all the listed points in order to submit consent for medical intervention; otherwise, they will encounter an error. It is done by adding custom validation to the field. Add custom validation to a field or the entire form to confirm the vaccination period, require medical files to be uploaded, or verify data accuracy.
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Patients confirm the accuracy of the data they have provided with a signature.