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

Patient

This visit

Emergency contact

Consent

फ़ॉर्म कोड

HTML
<!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>

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<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>
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<button type="submit" data-i18n="submit">Send</button>
<p data-status role="status"></p>
</form>
</main>
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