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 HIPAA-compliant form. You can personalize the vaccine request form to gather the information needed for COVID-19, flu, 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 or attach them to electronic medical records.
Structure and logic of the form
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The form content is organized 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 field accepts only valid phone numbers. You can select which country's formats are accepted in the field properties.
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The Medicare Number and Individual Health Identifier (IHI) fields accept only digits to prevent input errors. It is done with the Masked Input 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 field accepts only data matching a specified pattern to ensure valid email entries. Choose from predefined patterns or create custom ones to verify customer information.
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When patients answer 'yes' to any question, additional fields appear to collect more details. This is done with conditional rules in the Hide property.
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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 with a JavaScript function.
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Patients confirm the accuracy of the data they have provided with a signature.