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Kareo Help Center

View Patient Intake Online Form

Updated: 11/21/2019
Views: 1648

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 Kareo, which will allow for the practice to review and merge the information into a patient's chart. Providers can then review the submitted medical history. Patients will follow the steps below to complete the Patient Intake form. 

Available for Kareo Engage subscribers.

 

Date of Birth

The patient enters their date of birth for verification and clicks Submit. The Patient Form page opens.

PatientIntake_PatientView_DOB.png

Welcome Page

  1. The service location the patient appointment is scheduled at.
  2. Navigation:
    • Patients will need to fill out all required fields on the current section to move onto the next.
    • Patients will have the ability to click on the navigation to return to previous sections they have filled out.
    • Information entered 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. The patient clicks Get Started to begin. The Basic Information page opens.

PatientIntake_PatientView_Welcome.png
 

Basic Information

  1. Basic Information:
    • First Name and Last Name
    • Middle Name (optional)
    • Suffix (optional)
    • Sex
    • Date of Birth
    • Primary Phone Type
    • 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 opens.
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.

PatientIntake_PatientView_Basic.png

Demographics

All fields are optional.

  1. Demographics:
    • Sexual Orientation
    • Gender Identity
    • Language
    • Ethnicity
    • Hispanic or Latino
    • Race
    • Specific Races
  2. Click Next. The Emergency Contact page opens.
    • Click Back to go back to the previous page.

PatientIntake_PatientView_Demo.png

Emergency Contact

  1. Emergency Contact:
    • Relationship to Contact
    • First and Last Name
    • Middle Name (optional)
    • Primary Phone Type
    • Phone Number
    • Email (optional)
    • Address, City, State, and Zip (optional)
  2. Click Next. The Financial Information page opens.
    • Click Back to go back to the previous page.

PatientIntake_PatientView_ERContact.png

Financial Information

  1. Financial Information:
    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.
      • Other: 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 (optional)
          • Primary Phone Number
          • Phone Number
          • Social Security Number (optional)
          • Email (optional)
          • Address, City, State, and Zip (optional)
    2. Select a Method of Payment.
      • Self-Pay: The patient is financially responsible for all payments.
      • Insurance: The patient is covered by a payer. Populate the following information:
        • 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.
        • Enter the primary insurance information.
          • Insurance Company
          • Policy Number
          • Insurance Plan (optional)
          • Insurance Phone Number (optional)
          • Group Number (optional)
          • Address, City, State, and Zip (optional)
        • Select the Relationship to Primary Policy Holder, if necessary.
          • If the patient is not the primary policy holder, populate the following information:
            • First and Last Name
            • Middle Name (optional)
            • Insurance ID Number (optional)
            • Social Security Number (optional)
            • Sex (optional)
            • Address, City, State, and Zip (optional)
        • Click + Add another insurance to add a secondary insurance.
  2. Click Next. The Additional Information page opens.
    • Click Back to go back to the previous page.

PatientIntake_PatientView_Finanical.png

Additional Information

  1. Additional Information:
    1. Click Add Pharmacies to add a preferred pharmacy.
      1. Search by Pharmacy Name or Zip code.
      2. Click Select on the desired pharmacy. More than one may be selected.
      3. Click Select on the desired pharmacy. More than one may be selected.
      4. Click Add Pharmacies. The Add Pharmacies pop-up window closes.
    2. The patient can optionally select a referral source from the drop-down list.
  2. Click Next. The Consent Forms page opens.
    • Click Back to go back to the previous page.

PatientIntake_PatientView_AddInfo.png

Consent Forms

  1. If consent forms were sent, the patient will need to review the forms and answer available questions. Patient electronically sign the form by typing their name in the designated field.
  2. Click Next. The Medical History page opens.
    • Click Back to go back to the previous page.
PatientIntake_PatientView_Consent.png

Medication and Allergy

  1. The patient enters current medications they are taking and any allergies including reactions.
  2. Click Next. The Medical History page opens.
    • Click Back to go back to the previous section.

 

PatientIntake_PatientView_Meds.png

Medical History

  1. The Medical History section includes the following 6 pages:
    • Medical History: The patient can select applicable medical histories under Head, Ears, Nose/Sinuses, Mouth/Throat/Teeth, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Endocrine, Heme/Onc, Infections, Musculoskeletal, Skin, Neurological, and Psychiatric.
    • Family History: The patient can add family members, their known diseases, and health statuses.
    • Social History: The patient can select applicable social histories under Tobacco, Alcohol, Drug Abuse, Cardiovascular, Safety, Sexual Activity, and Birth Gender.
    • Past Surgical History: The patient can select applicable previous surgeries from the provided list and add comments.
    • Hospitalization/Procedure: The patient can add inpatient and outpatient procedures with applicable hospitalization dates.
    • Implantable Devices: The patient can add applicable implantable devices and unique identification numbers.
  2. Click Next to continue to the next page.
    • Click Back to go back to the previous page.
PatientIntake_PatientView_Medical.png

Review & Submit

  1. The patient can review all of the information they  entered prior to submitting their intake forms.
    • Click Edit to go back to the respective sections.
    • Click Print to save a copy of the consent form(s).
  2. Click Submit Form. The Confirmation page opens.
    • Click Back to go back to the previous section.

PatientIntake_PatientView_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.

PatientIntake_PatientView_Complete.png

 

 

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