Dermatology Patient Intake Form — shared by the community
Sam B. shared this 15-question build with 2 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 15 questions, 2 pages, 2 conditional rules.
- Shared by
- Sam B. · Customer success
- Questions
- 15
- Replies
- 8
- Copies taken
- 585
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Live preview and test console
This is the real form. Answer it to test the 1 conditional rule — nothing is sent or stored.
Page 1 of 2 — About you and your skin
1 question is hidden by conditional logic right now — change an answer above to reveal it.
Works for you? Take Sam B.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Dermatology Patient Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 15 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 10 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It collects a verified email address so replies and confirmations land.
- It captures a phone number for urgent follow-up.
- It accepts a document or photo upload as evidence.
- It pins the request to a specific date.
- Conditional logic hides 2 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Dermatology Patient Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Check the upload limits on the file question so respondents can attach what you actually need.
- 5Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 6Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 2 conditional rules ship with it.
- Features advanced show logic: if “Have you had this or a similar issue before?” is Yes, the form dynamically exposes “What was done about it before?”. Otherwise that question never appears.
- Features conditional validation: if “Any known allergies to skincare products or medications?” is Yes, “List allergies” becomes mandatory before the form can be sent.
- All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Page 1 — About you and your skin
- Patient full namerequired
- Date of birthrequired
- Phone numberrequired
- Email addressrequired
- Reason for this dermatology visitrequired
- How long has this been present?required
- Have you had this or a similar issue before?required
- What was done about it before?
Page 2 — History and skin care
- Do you have a family history of skin cancer?required
- Skin conditions you have been diagnosed with previously
- Do you use tanning beds or spend significant time outdoors?required
- Current skincare products and any medication applied to your skin
- Any known allergies to skincare products or medications?required
- List allergies
- Photo of the area, if helpful
Conditional logic in this build
- When “Have you had this or a similar issue before?” is Yes, show “What was done about it before?”.
- When “Any known allergies to skincare products or medications?” is Yes, require “List allergies”.
Questions about this shared form
Should the patient self-describe the mole or rash?
Yes. The form asks for the patient's own description and timeline; interpreting what it might be is left entirely to the clinician.
Is a photo required?
No, it is optional, since not every visit involves something visible in one spot, but it is genuinely useful for anything on the skin that changes day to day.
How is this different from the general Patient Intake Questionnaire?
That form covers general history for any first visit. This one is built around skin-specific questions a general intake does not ask.
Can it be used for a follow-up visit?
It works best for a first visit; for a follow-up, a shorter update on what has changed since the last appointment usually serves better.
Is the Dermatology Patient Intake Form template free to use?
Yes. You can preview and test Dermatology Patient Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Dermatology Patient Intake Form template ask for?
It asks 15 questions across 2 pages, 10 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Dermatology Patient Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
2 conditional rules ship with the template: Features advanced show logic: if “Have you had this or a similar issue before?” is Yes, the form dynamically exposes “What was done about it before?”. Otherwise that question never appears. Features conditional validation: if “Any known allergies to skincare products or medications?” is Yes, “List allergies” becomes mandatory before the form can be sent. All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other. All rules are editable in the Logic tab.
Where do responses to the Dermatology Patient Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Dermatology Patient Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Can respondents upload files?
Yes. This template includes a file upload question, so respondents can attach documents or photos with their answers. You can adjust the accepted file types and size limits on that question.
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