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Kareo Help Center

View Patient Intake Online Form

When users send intake forms to a patient, patients will receive an email with a link to the web forms. The web form will be responsive-- allowing patients to fill out their intake forms on a computer or on their smartphones and tablets. The link will expire after the appointment.

Information in these forms map back to the Kareo Platform, which will allow for the practice to review and merge the information into a patient's record.  

 

Welcome Page

  1. The service location the patient appointment is scheduled with.
  2. Navigation:
    • Patients will not be able to go to the next section until they fill out all required fields on the current section.
    • Patients will have the ability to click on the navigation to return to previous sections that they have filled out.
    • Information entered into the forms will auto-save, and patients will have the ability to return to the same link and see the information that they previously filled out.
  3. Click on Start Intake to begin. The Basic Information page will open.


Patient_Intake_Welcome.png

Basic Information

  1. Complete the Basic Information form. The patient will be asked to enter:
    • First Name and Last Name
    • Middle Name (optional)
    • Suffix (optional)
    • Sex
    • Date of Birth
    • Primary Phone Number
    • Email
    • Social Security Number (optional)
    • Address, City, State and Zip
    • Maiden Last Name (optional)
    • Martial Status (optional)
    • Driver's License photo, state and number.
      • Patients will have the ability to upload an image of their Driver's License/ID. If they are accessing the forms from a smartphone or tablet, they will also be able to easily take and upload a photo of their ID.
  2. Click Next. The Demographics page will open.
Note: Information entered into the forms will auto-save, with the exception of the Driver's License/ID and Insurance Card Front/Back images. If these images are uploaded and forms have not been submitted, when returning to the link, patients will find that the images are missing. They will need to upload the images again.

 

 

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Demographics

  1. Complete the Demographics form. All fields are optional.
    • Sexual Orientation
    • Gender Identity
    • Language
    • Ethnicity
    • Hispanic or Latino
    • Race
    • Specific Races
  2. Click Back to go back to the previous section or click Next. The Emergency Contact page will open.

 

Patient_Intake_Demographics.png

Emergency Contact

  1. Complete the Emergency Contact form. The patient will be asked to enter:
    • Relationship to Contact
    • First and Last Name
    • Middle Name (optional)
    • Phone Number
    • Email
    • Address, City, State and Zip
  2. Click Back to go back to the previous section or click Next. The Financial Information page will open.

 

Patient_Intake_Emergency_Contact.png

Financial Information

  1. Complete the Financial Information form.
    1. Select a Responsible Party.
      • Myself: The patient is the financially responsible for payment.
      • Same as emergency contact: The emergency contact is the financially responsible for payment.
      • Someone else: New contact is the financially responsible for payment.
        • If this option is selected, the patient will be asked to enter:
          • Relationship to Responsible Party
          • First and Last Name
          • Middle Name (optional)
          • Date of birth
          • Social Security Number (optional)
          • Phone Number
          • Email
          • Address, City, State and Zip

 

Patient_Intake_Financial_Info_Responsible_Party.png

  1. Select a Method of Payment.
    • Insurance: The patient is covered by a payer. If this option is selected, the patient will be asked to enter:
      1. Patients will have the ability to upload an image of the front and back of their insurance cards. If they are accessing the forms from a smartphone or tablet, they will also be able to easily take and upload the photos of the cards.
      2. Click How do I read my insurance card? to a view Commercial or Medicare Insurance Card example explaining where to find the information the patient needs to fill out the insurance fields in the form.
      3. Enter the primary insurance information. The patient will be asked to enter:
        • Insurance Company
        • Policy Number
        • Insurance Plan (optional)
        • Insurance Phone Number (optional)
        • Group Number (optional)
        • Address, City, State and Zip (optional)
      4. Select the Relationship to Primary Policy Holder.
        • If Spouse is select, the patient will be asked to enter:
          • First and Last Name
          • Middle Name (optional)
          • Social Security Number (optional)
          • Policy ID Number
          • Sex (optional)
          • Email
          • Address, City, State and Zip
      5. Click + Add another insurance to add a secondary insurance.
    • Self-Pay: The patient financially responsible for all payments.

2. Click Back to go back to the previous section or click Next. The Additional Information page will open.

 

Patient_Intake_Finanical_Info_Method.png

 

Additional Information

  1. Complete the Additional Information form. All fields are optional.
    • Preferred Pharmacy.
      1. Click Add Pharmacy.
      2. Search by Pharmacy Type, Pharmacy Name and Zipcode.
      3. Click Select on the desired pharmacy.
      4. Click Add Pharmacies.
    • How did you hear about us.
      1. The patient can enter how they were referred to the practice.
  2. Click Back to go back to the previous section or click Next. The Review & Submit page will open.

 

Patient_Intake_Additional.png

 

Review & Submit

  1. Patients will have the ability to review all of the information that they have entered prior to submitting their intake forms.
    • Click Edit to go back to the respective sections.
  2. Click Back to go back to the previous section or click Submit Form. The Confirmation page will open.

 

 

Patient_Intake_Review.png

 

Completed Form

Once the form has been submitted, patients will no longer be able to revisit the form to update any of their information. Upon submission, patients will see a confirmation as well as see the additional forms that the practice would like for them to download, print, fill out and bring in for the visit.

 

Patient_Intake_Complete.png

 

 

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