Patient intake form
First-visit details for a clinic. Leave out anything the visit does not need.
यह फ़ॉर्म मेडिकल रिकॉर्ड नहीं है। निदान, जाँच के नतीजे या अन्य स्वास्थ्य विवरण न भेजें जिनकी इस अनुरोध के लिए ज़रूरत नहीं है। स्वास्थ्य डेटा GDPR में विशेष श्रेणी है।
पूर्वावलोकन
फ़ॉर्म कोड
<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title>Patient intake form</title>
<style>
body { font-family: "Segoe UI", sans-serif; color: #12263a; margin: 0; background: #fff; }
main { max-width: 640px; margin: 0 auto; padding: 32px 20px 64px; }
h1 { font-size: 28px; font-weight: 650; letter-spacing: -0.02em; line-height: 1.2; }
h2 { font-size: 18px; margin: 18px 0 0; }
p { line-height: 1.5; }
form { display: grid; gap: 14px; position: relative; }
.field { display: grid; gap: 6px; }
label span, .check span { font-size: 14px; }
input, select, textarea { font: inherit; color: inherit; padding: 10px 12px; border: 1px solid #b4bdce; border-radius: 8px; width: 100%; box-sizing: border-box; background: #fff; }
textarea { min-height: 96px; }
.check { display: flex; gap: 8px; align-items: flex-start; }
.check input { width: auto; margin-top: 4px; }
button { background: #3c4ad8; color: #fff; border: 0; border-radius: 8px; padding: 12px 18px; font: inherit; cursor: pointer; }
.note { background: #fff6eb; padding: 12px 14px; border-radius: 8px; }
form [data-show-if] { display: none; }
form:has(select[name="medications"] option[value="yes"]:checked) [data-show-if="medications"][data-show-equals="yes"] { display: grid; }
</style>
</head>
<body>
<main>
<h1 data-i18n="title">Patient intake form</h1>
<p data-i18n="lede">First-visit details for a clinic. Leave out anything the visit does not need.</p>
<p class="note" data-i18n="disclaimer">This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.</p>
<form id="fg-form" action="https://formgong.com/submit" method="POST">
<input type="hidden" name="access_key" value="fk_your_access_key">
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden"><label>Leave this field empty<input name="botcheck" tabindex="-1" autocomplete="off"></label></div>
<section><h2 data-i18n="section.patient">Patient</h2>
<div class="field"><label for="fg-name"><span data-i18n="name">Name</span></label><input id="fg-name" name="name" type="text" required maxlength="80" autocomplete="name"></div>
<div class="field"><label for="fg-birth_date"><span data-i18n="birth_date">Date of birth</span></label><input id="fg-birth_date" name="birth_date" type="date" required></div>
<div class="field"><label for="fg-phone"><span data-i18n="phone">Phone</span></label><input id="fg-phone" name="phone" type="tel" required maxlength="40" autocomplete="tel"></div>
<div class="field"><label for="fg-email"><span data-i18n="email">Email</span></label><input id="fg-email" name="email" type="email" maxlength="120" autocomplete="email"></div></section>
<section><h2 data-i18n="section.visit">This visit</h2>
<div class="field"><label for="fg-first_visit"><span data-i18n="first_visit">Is this your first visit here?</span></label><select id="fg-first_visit" name="first_visit" required><option value="">—</option><option value="yes" data-i18n="first_visit.yes">Yes</option><option value="no" data-i18n="first_visit.no">No</option></select></div>
<div class="field"><label for="fg-reason"><span data-i18n="reason">Why are you coming in?</span></label><textarea id="fg-reason" name="reason" required maxlength="500"></textarea></div>
<div class="field"><label for="fg-medications"><span data-i18n="medications">Do you take regular medication the clinic should know about?</span></label><select id="fg-medications" name="medications" required><option value="">—</option><option value="yes" data-i18n="medications.yes">Yes</option><option value="no" data-i18n="medications.no">No</option></select></div>
<div class="field" data-show-if="medications" data-show-equals="yes"><label for="fg-medication_note"><span data-i18n="medication_note">Which medicines? Leave blank if the visit does not need the list.</span></label><textarea id="fg-medication_note" name="medication_note" maxlength="500"></textarea></div></section>
<section><h2 data-i18n="section.emergency">Emergency contact</h2>
<div class="field"><label for="fg-emergency_name"><span data-i18n="emergency_name">Name</span></label><input id="fg-emergency_name" name="emergency_name" type="text" maxlength="80" autocomplete="name"></div>
<div class="field"><label for="fg-emergency_phone"><span data-i18n="emergency_phone">Phone</span></label><input id="fg-emergency_phone" name="emergency_phone" type="tel" maxlength="40" autocomplete="tel"></div></section>
<section><h2 data-i18n="section.consent">Consent</h2>
<div class="field"><label class="check"><input id="fg-consent_contact" name="consent_contact" type="checkbox" value="yes" required><span data-i18n="consent_contact">I agree to be contacted about this request.</span></label></div>
<div class="field"><label class="check"><input id="fg-consent_privacy" name="consent_privacy" type="checkbox" value="yes" required><span data-i18n="consent_privacy">I agree that these answers are stored so the request can be handled.</span></label></div></section>
<!-- Turnstile hook: enable Turnstile on this form in Formgong, then set your site key.
<script src="https://challenges.cloudflare.com/turnstile/v0/api.js" async defer></script>
<div class="cf-turnstile" data-sitekey="YOUR_TURNSTILE_SITE_KEY"></div>
-->
<button type="submit" data-i18n="submit">Send</button>
<p data-status role="status"></p>
</form>
</main>
<script type="application/json" id="fg-labels">{"uk":{"title":"Форма первинного прийому пацієнта","lede":"Дані для першого візиту. Не додавайте те, без чого прийом можна провести.","submit":"Надіслати","thanks":"Надіслано. Дякуємо.","file_too_big":"Файл більший за 24 КБ. Додайте посилання.","disclaimer":"Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.","section.patient":"Пацієнт","name":"Ім'я","birth_date":"Дата народження","phone":"Телефон","email":"Електронна пошта","section.visit":"Цей візит","first_visit":"Це ваш перший візит сюди?","first_visit.yes":"Так","first_visit.no":"Ні","reason":"Чому ви приходите?","medications":"Чи є регулярні ліки, про які клініці варто знати?","medications.yes":"Так","medications.no":"Ні","medication_note":"Які ліки? Залиште порожнім, якщо для візиту список не потрібен.","section.emergency":"Екстрений контакт","emergency_name":"Ім'я","emergency_phone":"Телефон","section.consent":"Згода","consent_contact":"Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.","consent_privacy":"Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."},"en":{"title":"Patient intake form","lede":"First-visit details for a clinic. Leave out anything the visit does not need.","submit":"Send","thanks":"Sent. Thank you.","file_too_big":"That file is over 24 KB. Paste a link instead.","disclaimer":"This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.","section.patient":"Patient","name":"Name","birth_date":"Date of birth","phone":"Phone","email":"Email","section.visit":"This visit","first_visit":"Is this your first visit here?","first_visit.yes":"Yes","first_visit.no":"No","reason":"Why are you coming in?","medications":"Do you take regular medication the clinic should know about?","medications.yes":"Yes","medications.no":"No","medication_note":"Which medicines? Leave blank if the visit does not need the list.","section.emergency":"Emergency contact","emergency_name":"Name","emergency_phone":"Phone","section.consent":"Consent","consent_contact":"I agree to be contacted about this request.","consent_privacy":"I agree that these answers are stored so the request can be handled."},"pl":{"title":"Formularz wywiadu pacjenta","lede":"Dane na pierwszą wizytę. Pomiń to, bez czego wizyta może się odbyć.","submit":"Wyślij","thanks":"Wysłano. Dziękujemy.","file_too_big":"Plik ma ponad 24 KB. Wklej link.","disclaimer":"Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.","section.patient":"Pacjent","name":"Imię","birth_date":"Data urodzenia","phone":"Telefon","email":"E-mail","section.visit":"Ta wizyta","first_visit":"Czy to pierwsza wizyta tutaj?","first_visit.yes":"Tak","first_visit.no":"Nie","reason":"Po co przychodzisz?","medications":"Czy przyjmujesz leki, o których przychodnia powinna wiedzieć?","medications.yes":"Tak","medications.no":"Nie","medication_note":"Jakie leki? Zostaw puste, jeśli wizyta nie wymaga listy.","section.emergency":"Kontakt alarmowy","emergency_name":"Imię","emergency_phone":"Telefon","section.consent":"Zgoda","consent_contact":"Zgadzam się na kontakt w sprawie tego zgłoszenia.","consent_privacy":"Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."},"tr":{"title":"Hasta kabul formu","lede":"İlk ziyaret için bilgiler. Ziyaret onsuz yapılabiliyorsa eklemeyin.","submit":"Gönder","thanks":"Gönderildi. Teşekkürler.","file_too_big":"Dosya 24 KB'den büyük. Bağlantı ekleyin.","disclaimer":"Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.","section.patient":"Hasta","name":"Ad","birth_date":"Doğum tarihi","phone":"Telefon","email":"E-posta","section.visit":"Bu ziyaret","first_visit":"Buraya ilk gelişiniz mi?","first_visit.yes":"Evet","first_visit.no":"Hayır","reason":"Neden geliyorsunuz?","medications":"Kliniğin bilmesi gereken düzenli bir ilaç var mı?","medications.yes":"Evet","medications.no":"Hayır","medication_note":"Hangi ilaçlar? Ziyaret için liste gerekmiyorsa boş bırakın.","section.emergency":"Acil durumda","emergency_name":"Ad","emergency_phone":"Telefon","section.consent":"Onay","consent_contact":"Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.","consent_privacy":"Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."}}</script>
<script>
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apply();
var status = form.querySelector("[data-status]");
form.addEventListener("submit", function (event) {
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</body>
</html>
// Generated from src/content/industries.ts — npm run templates:write
import { useState } from "react";
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 24576;
const LABELS = {
"uk": {
"title": "Форма первинного прийому пацієнта",
"lede": "Дані для першого візиту. Не додавайте те, без чого прийом можна провести.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "Файл більший за 24 КБ. Додайте посилання.",
"disclaimer": "Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.",
"section.patient": "Пацієнт",
"name": "Ім'я",
"birth_date": "Дата народження",
"phone": "Телефон",
"email": "Електронна пошта",
"section.visit": "Цей візит",
"first_visit": "Це ваш перший візит сюди?",
"first_visit.yes": "Так",
"first_visit.no": "Ні",
"reason": "Чому ви приходите?",
"medications": "Чи є регулярні ліки, про які клініці варто знати?",
"medications.yes": "Так",
"medications.no": "Ні",
"medication_note": "Які ліки? Залиште порожнім, якщо для візиту список не потрібен.",
"section.emergency": "Екстрений контакт",
"emergency_name": "Ім'я",
"emergency_phone": "Телефон",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Patient intake form",
"lede": "First-visit details for a clinic. Leave out anything the visit does not need.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "That file is over 24 KB. Paste a link instead.",
"disclaimer": "This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.",
"section.patient": "Patient",
"name": "Name",
"birth_date": "Date of birth",
"phone": "Phone",
"email": "Email",
"section.visit": "This visit",
"first_visit": "Is this your first visit here?",
"first_visit.yes": "Yes",
"first_visit.no": "No",
"reason": "Why are you coming in?",
"medications": "Do you take regular medication the clinic should know about?",
"medications.yes": "Yes",
"medications.no": "No",
"medication_note": "Which medicines? Leave blank if the visit does not need the list.",
"section.emergency": "Emergency contact",
"emergency_name": "Name",
"emergency_phone": "Phone",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz wywiadu pacjenta",
"lede": "Dane na pierwszą wizytę. Pomiń to, bez czego wizyta może się odbyć.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Plik ma ponad 24 KB. Wklej link.",
"disclaimer": "Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.",
"section.patient": "Pacjent",
"name": "Imię",
"birth_date": "Data urodzenia",
"phone": "Telefon",
"email": "E-mail",
"section.visit": "Ta wizyta",
"first_visit": "Czy to pierwsza wizyta tutaj?",
"first_visit.yes": "Tak",
"first_visit.no": "Nie",
"reason": "Po co przychodzisz?",
"medications": "Czy przyjmujesz leki, o których przychodnia powinna wiedzieć?",
"medications.yes": "Tak",
"medications.no": "Nie",
"medication_note": "Jakie leki? Zostaw puste, jeśli wizyta nie wymaga listy.",
"section.emergency": "Kontakt alarmowy",
"emergency_name": "Imię",
"emergency_phone": "Telefon",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Hasta kabul formu",
"lede": "İlk ziyaret için bilgiler. Ziyaret onsuz yapılabiliyorsa eklemeyin.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "Dosya 24 KB'den büyük. Bağlantı ekleyin.",
"disclaimer": "Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.",
"section.patient": "Hasta",
"name": "Ad",
"birth_date": "Doğum tarihi",
"phone": "Telefon",
"email": "E-posta",
"section.visit": "Bu ziyaret",
"first_visit": "Buraya ilk gelişiniz mi?",
"first_visit.yes": "Evet",
"first_visit.no": "Hayır",
"reason": "Neden geliyorsunuz?",
"medications": "Kliniğin bilmesi gereken düzenli bir ilaç var mı?",
"medications.yes": "Evet",
"medications.no": "Hayır",
"medication_note": "Hangi ilaçlar? Ziyaret için liste gerekmiyorsa boş bırakın.",
"section.emergency": "Acil durumda",
"emergency_name": "Ad",
"emergency_phone": "Telefon",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
export function IndustryForm({ lang = "en", accessKey = "fk_your_access_key" }) {
const t = LABELS[lang] || LABELS.en;
const [status, setStatus] = useState("");
const [values, setValues] = useState({ medications: "" });
function setField(name, value) {
setValues((current) => ({ ...current, [name]: value }));
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = {};
const files = [];
for (const [key, value] of new FormData(form).entries()) {
if (value instanceof File) {
if (value.size) files.push([key, value]);
continue;
}
body[key] = String(value);
}
if (files.some((pair) => pair[1].size > FILE_MAX)) {
setStatus(t.file_too_big);
return;
}
for (const [key, file] of files) {
body[key + "_filename"] = file.name;
body[key + "_data"] = await readFile(file);
}
const response = await fetch(ENDPOINT, {
method: "POST",
headers: { "Content-Type": "application/json", Accept: "application/json" },
body: JSON.stringify(body),
});
const result = await response.json();
setStatus(result.success ? t.thanks : (result.message || "error"));
}
return (
<form onSubmit={onSubmit}>
<h1>{t.title}</h1>
<p>{t.lede}</p>
{t.disclaimer ? <p>{t.disclaimer}</p> : null}
<input type="hidden" name="access_key" value={accessKey} />
<div aria-hidden="true" style={{ position: "absolute", left: "-10000px", width: 1, height: 1, overflow: "hidden" }}>
<input name="botcheck" tabIndex={-1} autoComplete="off" />
</div>
<section><h2>{t["section.patient"]}</h2>
<label><span>{t["name"]}</span><input name="name" type="text" required maxLength={80} autoComplete="name" /></label>
<label><span>{t["birth_date"]}</span><input name="birth_date" type="date" required /></label>
<label><span>{t["phone"]}</span><input name="phone" type="tel" required maxLength={40} autoComplete="tel" /></label>
<label><span>{t["email"]}</span><input name="email" type="email" maxLength={120} autoComplete="email" /></label></section>
<section><h2>{t["section.visit"]}</h2>
<label><span>{t["first_visit"]}</span><select name="first_visit" required><option value="">—</option><option value="yes">{t["first_visit.yes"]}</option><option value="no">{t["first_visit.no"]}</option></select></label>
<label><span>{t["reason"]}</span><textarea name="reason" required maxLength={500} /></label>
<label><span>{t["medications"]}</span><select name="medications" required value={values["medications"]} onChange={(event) => setField("medications", event.target.value)}><option value="">—</option><option value="yes">{t["medications.yes"]}</option><option value="no">{t["medications.no"]}</option></select></label>
{values["medications"] === "yes" ? (<label><span>{t["medication_note"]}</span><textarea name="medication_note" maxLength={500} /></label>) : null}</section>
<section><h2>{t["section.emergency"]}</h2>
<label><span>{t["emergency_name"]}</span><input name="emergency_name" type="text" maxLength={80} autoComplete="name" /></label>
<label><span>{t["emergency_phone"]}</span><input name="emergency_phone" type="tel" maxLength={40} autoComplete="tel" /></label></section>
<section><h2>{t["section.consent"]}</h2>
<label className="check"><input name="consent_contact" type="checkbox" value="yes" required /><span>{t["consent_contact"]}</span></label>
<label className="check"><input name="consent_privacy" type="checkbox" value="yes" required /><span>{t["consent_privacy"]}</span></label></section>
{/* Turnstile hook: enable Turnstile on this form in Formgong, load https://challenges.cloudflare.com/turnstile/v0/api.js, and render <div className="cf-turnstile" data-sitekey="YOUR_TURNSTILE_SITE_KEY" /> */}
<button type="submit">{t.submit}</button>
<p>{status}</p>
</form>
);
}
function readFile(file) {
return new Promise((resolve, reject) => {
const reader = new FileReader();
reader.onload = () => {
const raw = String(reader.result || "");
const comma = raw.indexOf(",");
resolve(comma === -1 ? raw : raw.slice(comma + 1));
};
reader.onerror = () => reject(reader.error);
reader.readAsDataURL(file);
});
}
<!-- Generated from src/content/industries.ts — npm run templates:write -->
<script setup>
import { reactive, ref, computed } from "vue";
const props = defineProps({
lang: { type: String, default: "en" },
accessKey: { type: String, default: "fk_your_access_key" },
});
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 24576;
const LABELS = {
"uk": {
"title": "Форма первинного прийому пацієнта",
"lede": "Дані для першого візиту. Не додавайте те, без чого прийом можна провести.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "Файл більший за 24 КБ. Додайте посилання.",
"disclaimer": "Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.",
"section.patient": "Пацієнт",
"name": "Ім'я",
"birth_date": "Дата народження",
"phone": "Телефон",
"email": "Електронна пошта",
"section.visit": "Цей візит",
"first_visit": "Це ваш перший візит сюди?",
"first_visit.yes": "Так",
"first_visit.no": "Ні",
"reason": "Чому ви приходите?",
"medications": "Чи є регулярні ліки, про які клініці варто знати?",
"medications.yes": "Так",
"medications.no": "Ні",
"medication_note": "Які ліки? Залиште порожнім, якщо для візиту список не потрібен.",
"section.emergency": "Екстрений контакт",
"emergency_name": "Ім'я",
"emergency_phone": "Телефон",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Patient intake form",
"lede": "First-visit details for a clinic. Leave out anything the visit does not need.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "That file is over 24 KB. Paste a link instead.",
"disclaimer": "This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.",
"section.patient": "Patient",
"name": "Name",
"birth_date": "Date of birth",
"phone": "Phone",
"email": "Email",
"section.visit": "This visit",
"first_visit": "Is this your first visit here?",
"first_visit.yes": "Yes",
"first_visit.no": "No",
"reason": "Why are you coming in?",
"medications": "Do you take regular medication the clinic should know about?",
"medications.yes": "Yes",
"medications.no": "No",
"medication_note": "Which medicines? Leave blank if the visit does not need the list.",
"section.emergency": "Emergency contact",
"emergency_name": "Name",
"emergency_phone": "Phone",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz wywiadu pacjenta",
"lede": "Dane na pierwszą wizytę. Pomiń to, bez czego wizyta może się odbyć.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Plik ma ponad 24 KB. Wklej link.",
"disclaimer": "Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.",
"section.patient": "Pacjent",
"name": "Imię",
"birth_date": "Data urodzenia",
"phone": "Telefon",
"email": "E-mail",
"section.visit": "Ta wizyta",
"first_visit": "Czy to pierwsza wizyta tutaj?",
"first_visit.yes": "Tak",
"first_visit.no": "Nie",
"reason": "Po co przychodzisz?",
"medications": "Czy przyjmujesz leki, o których przychodnia powinna wiedzieć?",
"medications.yes": "Tak",
"medications.no": "Nie",
"medication_note": "Jakie leki? Zostaw puste, jeśli wizyta nie wymaga listy.",
"section.emergency": "Kontakt alarmowy",
"emergency_name": "Imię",
"emergency_phone": "Telefon",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Hasta kabul formu",
"lede": "İlk ziyaret için bilgiler. Ziyaret onsuz yapılabiliyorsa eklemeyin.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "Dosya 24 KB'den büyük. Bağlantı ekleyin.",
"disclaimer": "Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.",
"section.patient": "Hasta",
"name": "Ad",
"birth_date": "Doğum tarihi",
"phone": "Telefon",
"email": "E-posta",
"section.visit": "Bu ziyaret",
"first_visit": "Buraya ilk gelişiniz mi?",
"first_visit.yes": "Evet",
"first_visit.no": "Hayır",
"reason": "Neden geliyorsunuz?",
"medications": "Kliniğin bilmesi gereken düzenli bir ilaç var mı?",
"medications.yes": "Evet",
"medications.no": "Hayır",
"medication_note": "Hangi ilaçlar? Ziyaret için liste gerekmiyorsa boş bırakın.",
"section.emergency": "Acil durumda",
"emergency_name": "Ad",
"emergency_phone": "Telefon",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
const t = computed(() => LABELS[props.lang] || LABELS.en);
const status = ref("");
const values = reactive({ medications: "" });
function readFile(file) {
return new Promise((resolve, reject) => {
const reader = new FileReader();
reader.onload = () => {
const raw = String(reader.result || "");
const comma = raw.indexOf(",");
resolve(comma === -1 ? raw : raw.slice(comma + 1));
};
reader.onerror = () => reject(reader.error);
reader.readAsDataURL(file);
});
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = {};
const files = [];
for (const [key, value] of new FormData(form).entries()) {
if (value instanceof File) {
if (value.size) files.push([key, value]);
continue;
}
body[key] = String(value);
}
if (files.some((pair) => pair[1].size > FILE_MAX)) {
status.value = t.value.file_too_big;
return;
}
for (const [key, file] of files) {
body[key + "_filename"] = file.name;
body[key + "_data"] = await readFile(file);
}
const response = await fetch(ENDPOINT, {
method: "POST",
headers: { "Content-Type": "application/json", Accept: "application/json" },
body: JSON.stringify(body),
});
const result = await response.json();
status.value = result.success ? t.value.thanks : (result.message || "error");
}
</script>
<template>
<form @submit.prevent="onSubmit">
<h1>{{ t.title }}</h1>
<p>{{ t.lede }}</p>
<p v-if="t.disclaimer">{{ t.disclaimer }}</p>
<input type="hidden" name="access_key" :value="accessKey">
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden">
<input name="botcheck" tabindex="-1" autocomplete="off">
</div>
<section><h2>{{ t["section.patient"] }}</h2>
<label><span>{{ t["name"] }}</span><input name="name" type="text" required maxlength="80" autocomplete="name"></label>
<label><span>{{ t["birth_date"] }}</span><input name="birth_date" type="date" required></label>
<label><span>{{ t["phone"] }}</span><input name="phone" type="tel" required maxlength="40" autocomplete="tel"></label>
<label><span>{{ t["email"] }}</span><input name="email" type="email" maxlength="120" autocomplete="email"></label></section>
<section><h2>{{ t["section.visit"] }}</h2>
<label><span>{{ t["first_visit"] }}</span><select name="first_visit" required><option value="">—</option><option value="yes">{{ t["first_visit.yes"] }}</option><option value="no">{{ t["first_visit.no"] }}</option></select></label>
<label><span>{{ t["reason"] }}</span><textarea name="reason" required maxlength="500"></textarea></label>
<label><span>{{ t["medications"] }}</span><select name="medications" required v-model="values.medications"><option value="">—</option><option value="yes">{{ t["medications.yes"] }}</option><option value="no">{{ t["medications.no"] }}</option></select></label>
<template v-if="values["medications"] === 'yes'"><label><span>{{ t["medication_note"] }}</span><textarea name="medication_note" maxlength="500"></textarea></label></template></section>
<section><h2>{{ t["section.emergency"] }}</h2>
<label><span>{{ t["emergency_name"] }}</span><input name="emergency_name" type="text" maxlength="80" autocomplete="name"></label>
<label><span>{{ t["emergency_phone"] }}</span><input name="emergency_phone" type="tel" maxlength="40" autocomplete="tel"></label></section>
<section><h2>{{ t["section.consent"] }}</h2>
<label class="check"><input name="consent_contact" type="checkbox" value="yes" required><span>{{ t["consent_contact"] }}</span></label>
<label class="check"><input name="consent_privacy" type="checkbox" value="yes" required><span>{{ t["consent_privacy"] }}</span></label></section>
<!-- Turnstile hook: enable Turnstile on this form in Formgong, add the api.js script, and a div.cf-turnstile with data-sitekey="YOUR_TURNSTILE_SITE_KEY". -->
<button type="submit">{{ t.submit }}</button>
<p>{{ status }}</p>
</form>
</template>
<!-- Generated from src/content/industries.ts — npm run templates:write -->
<script>
let { lang = "en", accessKey = "fk_your_access_key" } = $props();
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 24576;
const LABELS = {
"uk": {
"title": "Форма первинного прийому пацієнта",
"lede": "Дані для першого візиту. Не додавайте те, без чого прийом можна провести.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "Файл більший за 24 КБ. Додайте посилання.",
"disclaimer": "Ця форма не є медичним записом. Не надсилайте діагнози, результати аналізів чи інші дані про здоров'я, без яких заявку не обробити. Дані про здоров'я — особлива категорія за GDPR.",
"section.patient": "Пацієнт",
"name": "Ім'я",
"birth_date": "Дата народження",
"phone": "Телефон",
"email": "Електронна пошта",
"section.visit": "Цей візит",
"first_visit": "Це ваш перший візит сюди?",
"first_visit.yes": "Так",
"first_visit.no": "Ні",
"reason": "Чому ви приходите?",
"medications": "Чи є регулярні ліки, про які клініці варто знати?",
"medications.yes": "Так",
"medications.no": "Ні",
"medication_note": "Які ліки? Залиште порожнім, якщо для візиту список не потрібен.",
"section.emergency": "Екстрений контакт",
"emergency_name": "Ім'я",
"emergency_phone": "Телефон",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Patient intake form",
"lede": "First-visit details for a clinic. Leave out anything the visit does not need.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "That file is over 24 KB. Paste a link instead.",
"disclaimer": "This form is not a medical record. Do not send diagnoses, test results, or other health details you do not need for the request. Health data is a special category under the GDPR.",
"section.patient": "Patient",
"name": "Name",
"birth_date": "Date of birth",
"phone": "Phone",
"email": "Email",
"section.visit": "This visit",
"first_visit": "Is this your first visit here?",
"first_visit.yes": "Yes",
"first_visit.no": "No",
"reason": "Why are you coming in?",
"medications": "Do you take regular medication the clinic should know about?",
"medications.yes": "Yes",
"medications.no": "No",
"medication_note": "Which medicines? Leave blank if the visit does not need the list.",
"section.emergency": "Emergency contact",
"emergency_name": "Name",
"emergency_phone": "Phone",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz wywiadu pacjenta",
"lede": "Dane na pierwszą wizytę. Pomiń to, bez czego wizyta może się odbyć.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Plik ma ponad 24 KB. Wklej link.",
"disclaimer": "Ten formularz nie jest dokumentacją medyczną. Nie wysyłaj rozpoznań, wyników badań ani innych danych o zdrowiu, które nie są potrzebne do obsługi zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO.",
"section.patient": "Pacjent",
"name": "Imię",
"birth_date": "Data urodzenia",
"phone": "Telefon",
"email": "E-mail",
"section.visit": "Ta wizyta",
"first_visit": "Czy to pierwsza wizyta tutaj?",
"first_visit.yes": "Tak",
"first_visit.no": "Nie",
"reason": "Po co przychodzisz?",
"medications": "Czy przyjmujesz leki, o których przychodnia powinna wiedzieć?",
"medications.yes": "Tak",
"medications.no": "Nie",
"medication_note": "Jakie leki? Zostaw puste, jeśli wizyta nie wymaga listy.",
"section.emergency": "Kontakt alarmowy",
"emergency_name": "Imię",
"emergency_phone": "Telefon",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Hasta kabul formu",
"lede": "İlk ziyaret için bilgiler. Ziyaret onsuz yapılabiliyorsa eklemeyin.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "Dosya 24 KB'den büyük. Bağlantı ekleyin.",
"disclaimer": "Bu form bir tıbbi kayıt değildir. Tanı, tahlil sonucu veya talep için gerekmeyen başka sağlık verisi göndermeyin. Sağlık verisi GDPR'de özel nitelikli veridir.",
"section.patient": "Hasta",
"name": "Ad",
"birth_date": "Doğum tarihi",
"phone": "Telefon",
"email": "E-posta",
"section.visit": "Bu ziyaret",
"first_visit": "Buraya ilk gelişiniz mi?",
"first_visit.yes": "Evet",
"first_visit.no": "Hayır",
"reason": "Neden geliyorsunuz?",
"medications": "Kliniğin bilmesi gereken düzenli bir ilaç var mı?",
"medications.yes": "Evet",
"medications.no": "Hayır",
"medication_note": "Hangi ilaçlar? Ziyaret için liste gerekmiyorsa boş bırakın.",
"section.emergency": "Acil durumda",
"emergency_name": "Ad",
"emergency_phone": "Telefon",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
let status = $state("");
let values = $state({ medications: "" });
const t = $derived(LABELS[lang] || LABELS.en);
function readFile(file) {
return new Promise((resolve, reject) => {
const reader = new FileReader();
reader.onload = () => {
const raw = String(reader.result || "");
const comma = raw.indexOf(",");
resolve(comma === -1 ? raw : raw.slice(comma + 1));
};
reader.onerror = () => reject(reader.error);
reader.readAsDataURL(file);
});
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = {};
const files = [];
for (const [key, value] of new FormData(form).entries()) {
if (value instanceof File) {
if (value.size) files.push([key, value]);
continue;
}
body[key] = String(value);
}
if (files.some((pair) => pair[1].size > FILE_MAX)) {
status = t.file_too_big;
return;
}
for (const [key, file] of files) {
body[key + "_filename"] = file.name;
body[key + "_data"] = await readFile(file);
}
const response = await fetch(ENDPOINT, {
method: "POST",
headers: { "Content-Type": "application/json", Accept: "application/json" },
body: JSON.stringify(body),
});
const result = await response.json();
status = result.success ? t.thanks : (result.message || "error");
}
</script>
<form onsubmit={onSubmit}>
<h1>{t.title}</h1>
<p>{t.lede}</p>
{#if t.disclaimer}<p>{t.disclaimer}</p>{/if}
<input type="hidden" name="access_key" value={accessKey}>
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden">
<input name="botcheck" tabindex="-1" autocomplete="off">
</div>
<section><h2>{t["section.patient"]}</h2>
<label><span>{t["name"]}</span><input name="name" type="text" required maxlength="80"></label>
<label><span>{t["birth_date"]}</span><input name="birth_date" type="date" required></label>
<label><span>{t["phone"]}</span><input name="phone" type="tel" required maxlength="40"></label>
<label><span>{t["email"]}</span><input name="email" type="email" maxlength="120"></label></section>
<section><h2>{t["section.visit"]}</h2>
<label><span>{t["first_visit"]}</span><select name="first_visit" required><option value="">—</option><option value="yes">{t["first_visit.yes"]}</option><option value="no">{t["first_visit.no"]}</option></select></label>
<label><span>{t["reason"]}</span><textarea name="reason" required maxlength="500"></textarea></label>
<label><span>{t["medications"]}</span><select name="medications" required bind:value={values.medications}><option value="">—</option><option value="yes">{t["medications.yes"]}</option><option value="no">{t["medications.no"]}</option></select></label>
{#if values.medications === "yes"}<label><span>{t["medication_note"]}</span><textarea name="medication_note" maxlength="500"></textarea></label>{/if}</section>
<section><h2>{t["section.emergency"]}</h2>
<label><span>{t["emergency_name"]}</span><input name="emergency_name" type="text" maxlength="80"></label>
<label><span>{t["emergency_phone"]}</span><input name="emergency_phone" type="tel" maxlength="40"></label></section>
<section><h2>{t["section.consent"]}</h2>
<label class="check"><input name="consent_contact" type="checkbox" value="yes" required><span>{t["consent_contact"]}</span></label>
<label class="check"><input name="consent_privacy" type="checkbox" value="yes" required><span>{t["consent_privacy"]}</span></label></section>
<!-- Turnstile hook: enable Turnstile on this form in Formgong, add the api.js script, and a div.cf-turnstile with data-sitekey="YOUR_TURNSTILE_SITE_KEY". -->
<button type="submit">{t.submit}</button>
<p>{status}</p>
</form>