Healthcare Form Templates

Browse the healthcare form templates

Need some help getting started with Hush™ Secure Forms? We have a collection of healthcare form templates you can use as a starting point for your form. It’s a great way to find inspiration, or to find a completed template that already works for your business.

Hush™ Secure Forms is our secure, digital alternative to old-fashioned paper forms. You can launch a beautiful, personalized web form for your business in minutes with our drag-and-drop form builder, template directory, and built-in secure web hosting.

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General Healthcare

Request an Appointment (Behavioral Health)

A counseling appointment request form. You can link to this form from your website, social media, and email signature. Your customers can use the form to request an appointment with you.

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Intake Form (Adult)

A general intake form for adult clients. You can send this questionnaire to your new clients, to be completed prior to their first appointment.

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Intake form (Child)

A general intake form for child clients. You can send this questionnaire to the parents or guardians of your new clients, to be completed prior to their first appointment.

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Client Experience Survey

A client experience survey. After an appointment, send this survey to your clients to find out what went well, and how they think you can improve.

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Patient Health Questionnaire (PHQ-9)

PHQ-9 is a questionnaire used by qualified professionals to help diagnose, monitor and measure the severity of depression.

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Dental Intake Form

A new dental patient form for your dental practice. You can send this form to your patients prior to their first appointment.

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Request an Appointment (Dental)

A dental appointment request form. You can link to this form from your website, social media, and email signature. Your customers can use the form to request an appointment with you.

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General Anxiety Disorder (GAD-7)

GAD-7 is a questionnaire which can be used by qualified professionals to help diagnose, monitor and measure the severity of anxiety.

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COVID-19 Screening Questionnaire

A COVID-19 screening questionnaire for your clients to complete before their appointment. You can modify the form as needed to comply with local health advice.

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Depression Anxiety Stress Scales (DASS)

The DASS is a 42-item questionnaire designed to help qualified professionals measure the three related negative emotional states of depression, anxiety and tension/stress.

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Depression Anxiety Stress Scales (DASS-21)

The DASS-21 is a 21-item questionnaire designed to help qualified professionals measure the three related negative emotional states of depression, anxiety and tension/stress.

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Massage Therapy Intake Form

An intake form for massage therapy patients. You can send this questionnaire to your new clients, to be completed prior to their first appointment.

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Chiropractic Intake Form

An intake form for chiropractic clients. You can send this questionnaire to your new clients, to be completed prior to their first appointment.

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Physical Therapy Intake Form

An intake form for physical therapy clients. You can send this questionnaire to your new clients, to be completed prior to their first appointment.

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PTSD Checklist for DSM-5 (PCL-5)

The PCL-5 is a questionnaire used by qualified professionals to help diagnose, monitor and measure the severity of PTSD. Includes support for the optional LEC-5 and Criterion A formats as well as monthly and weekly formats.

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Alcohol Use Disorders Identification Test (AUDIT)

AUDIT is a questionnaire which can be used by qualified professionals to identify people who would benefit from reducing or ceasing alcohol consumption.

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Therapy Intake Form (Adult)

An intake form for your therapy clients to be completed by adults. You can send this questionnaire to your new clients, to be completed prior to their first appointment.

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Therapy Intake Form (Child)

An intake form for your therapy clients to be completed for the child. You can send this questionnaire to your new clients, to be completed prior to their first appointment.

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Informed Consent for In-Person Services During the COVID-19 Public Health Crisis

This consent form is used by psychologists when returning to in-person services during COVID-19. Please modify the form according to the policies in your office and health region.

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Screen for Child Anxiety Related Disorders (SCARED) - Child Version

SCARED is a questionnaire used by qualified professionals to screen for anxiety related disorders. This version is for the child to complete.

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Screen for Child Anxiety Related Disorders (SCARED) - Parent Version

SCARED is a questionnaire used by qualified professionals to screen for anxiety related disorders. This version is for the parent to complete about the child.

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Screen for Adult Anxiety Related Disorders (SCAARED)

SCAARED is a questionnaire used by qualified professionals to screen for anxiety related disorders. This version is for adults over the age of 18.

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Good Faith Estimate

A Good Faith Estimate template suitable for sole practitioners working at a single location. This form is completed by the practitioner. The client receives a copy of the completed form.

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Try Hush™ Secure Forms risk-free for 60 days

Hushmail for Healthcare includes Encrypted Email and a Private Message Center with optional Secure Forms and Electronic Signatures. We'll include a signed Business Associate Agreement (BAA) and Email Archiving to help with your HIPAA compliance.

Overview

Starter

$
11.99
per month

Recommended

$
24.99
per month

Custom

Speak to Sales for custom pricing
Encrypted email accounts 1 Up to 5
Up to
Secure web forms Not included Up to 5
Up to
Electronic signatures Not included Included Included
HIPAA-Compliant Service Included Included Included
Done-For-You Form Building Service $25 per form built Not included Not included $25 per form built Up to 2 forms Up to 2 forms $25 per form built Up to 5 forms Up to 5 forms
60-day money back guarantee Included Included Included
Available plan add-ons (purchase during checkout)
Add 1 email
+$5/mo
Add 3 forms and email templates
+$3/mo
Add 1 email
+$55/yr
Add 3 forms and email templates
+$33/yr
Add 1 email
+$105/2 yr
Add 3 forms and email templates
+$63/2 yr
Add 1 email
and form
+$5/mo
Add 1 email
and form
+$55/yr
Add 1 email
and form
+$105/2 yr
Encrypted Email
Webmail (desktop & mobile) Included Included Included
Works with email apps (e.g. Outlook) Included Included Included
Hushmail for iPhone Included Included Included
Custom domain (@yourcompany.com) Included Included Included
Send & receive encrypted file attachments Included Included Included
Email templates With add-on Included Included
Email aliases Unlimited Unlimited Unlimited
Storage (per email account) 10 GB 15 GB 10 GB
Secure Web Forms
Monthly form submissions Unlimited Unlimited
Maximum pages per form Unlimited Unlimited
Ready-made form templates With add-on Included Included
Calculated questionnaires (e.g. PHQ-9) With add-on Included Included
Design your own forms With add-on Included Included
Receive form submissions as PDFs With add-on Included Included
Conditional field visibility With add-on Included Included
Share forms with colleagues Not included Included Included
Body charts Not included Included Included
Electronic Signatures
Sign on desktop and mobile Not included Included Included
Detailed activity records Not included Included Included
ESIGN and UETA compliant Not included Included Included
One signer per form Not included Included Included
Multiple signers per form Not included Not included Coming soon
Private Message Center
Maximum clients per month Unlimited Unlimited Unlimited
Clients can send secure replies Included Included Included
Clients can sign in with their Google, Apple, or Microsoft account Included Included Included
Customization & Branding
Custom logo Not included Included Included
Custom secure web form accent color Not included Included Included
Remove Powered by logo from forms Not included Not included Included
Customer Care
One-on-one setup assistance by phone Included Included Included
Technical support by phone and email Included Included Included
Online knowledge base Included Included Included
Security & Compliance
Business Associate Agreement HIPAA Included Included Included
Email archiving HIPAA Included Included Included
Information Manager Agreement (Canada) Included Included Included
Two-step verification Included Included Included
Encryption OpenPGP & SSL OpenPGP & SSL OpenPGP & SSL
Domain Administration (if using a custom domain)
Standard email forwarding Included Included Included
Catch-all email forwarding Included Included Included
Manage user accounts Not included Included Included
Expand all features

All prices displayed are in US dollars. Taxes may apply. Full refund if you cancel within 60 days.

Hushmail for Small Business includes Encrypted Email, a Private Message Center, and an Email Archive, with optional Secure Forms and Electronic Signatures.

Overview

Professional

$
10.79
per month

Plus

$
22.49
per month

Team

Speak to Sales for custom pricing
Encrypted email accounts 1 Up to 5
Up to
Secure web forms Not included Up to 5
Up to
Electronic signatures Not included Included Included
HIPAA-Compliance ❌ ❌ ❌
Information Manager Agreement (IMA) ❌ ❌ ❌
60-day money back guarantee Included Included Included
Available plan add-ons1 (purchase during checkout)
Add 1 email
+$4.50/mo
Add 3 forms and email templates
+$2.70/mo
Add 1 email
+$49.50/yr
Add 3 forms and email templates
+$29.70/yr
Add 1 email
+$94.50/2 yr
Add 3 forms and email templates
+$56.70/2 yr
Add 1 email
and form
+$4.50/mo
Add 1 email
and form
+$49.50/yr
Add 1 email
and form
+$94.50/2 yr
Encrypted Email
Webmail (desktop & mobile) Included Included Included
Works with email apps (e.g. Outlook) Included Included Included
Hushmail for iPhone Included Included Included
Custom domain (@yourcompany.com) Included Included Included
Send & receive encrypted file attachments Included Included Included
Email templates With add-on Included Included
Email aliases Unlimited Unlimited Unlimited
Storage (per email account) 10 GB 15 GB 15 GB
Secure Web Forms
Monthly form submissions Unlimited Unlimited
Maximum pages per form Unlimited Unlimited
Ready-made form templates With add-on Included Included
Calculated questionnaires (e.g. PHQ-9) With add-on Included Included
Design your own forms With add-on Included Included
Receive form submissions as PDFs With add-on Included Included
Conditional field visibility With add-on Included Included
Share forms with colleagues Not included Included Included
Electronic Signatures
Sign on desktop and mobile Not included Included Included
Detailed activity records Not included Included Included
ESIGN and UETA compliant Not included Included Included
One signer per form Not included Included Included
Multiple signers per form Not included Not included Coming soon
Private Message Center
Maximum clients per month Unlimited Unlimited Unlimited
Clients can send secure replies Included Included Included
Clients can sign in with their Google, Apple, or Microsoft account Included Included Included
Customization & Branding
Custom logo Not included Included Included
Custom secure web form accent color Not included Included Included
Remove Powered by logo from forms Not included Not included Included
Customer Care
One-on-one setup assistance by phone Included Included Included
Technical support by phone and email Included Included Included
Online knowledge base Included Included Included
Security & Compliance
Email archiving Included Included Included
Two-step verification Included Included Included
Encryption OpenPGP & SSL OpenPGP & SSL OpenPGP & SSL
Domain Administration (if using a custom domain)
Standard email forwarding Included Included Included
Catch-all email forwarding Included Included Included
Manage user accounts Not included Included Included
Expand all features

All prices displayed are in US dollars. Taxes may apply. Full refund if you cancel within 60 days.

Hushmail for Law includes Encrypted Email, a Private Message Center, and an Email Archive, with optional Secure Forms and Electronic Signatures. Plus, we'll sign an agreement with customers in the U.S., Canada and the U.K. to seek judicial protection for the account, if necessary, on the basis that the contents are privileged, providing extra protection for your communications.

Overview

Professional

$
10.79
per month

Plus

$
22.49
per month

Team

Speak to Sales for custom pricing
Encrypted email accounts 1 Up to 5
Up to
Secure web forms Not included Up to 5
Up to
Electronic signatures Not included Included Included
HIPAA-Compliance ❌ ❌ ❌
Information Manager Agreement (IMA) ❌ ❌ ❌
60-day money back guarantee Included Included Included
Available plan add-ons1 (purchase during checkout)
Add 1 email
+$4.50/mo
Add 3 forms and email templates
+$2.70/mo
Add 1 email
+$49.50/yr
Add 3 forms and email templates
+$29.70/yr
Add 1 email
+$94.50/2 yr
Add 3 forms and email templates
+$56.70/2 yr
Add 1 email
and form
+$4.50/mo
Add 1 email
and form
+$49.50/yr
Add 1 email
and form
+$94.50/2 yr
Encrypted Email
Webmail (desktop & mobile) Included Included Included
Works with email apps (e.g. Outlook) Included Included Included
Hushmail for iPhone Included Included Included
Custom domain (@yourcompany.com) Included Included Included
Send & receive encrypted file attachments Included Included Included
Email templates With add-on Included Included
Email aliases Unlimited Unlimited Unlimited
Storage (per email account) 10 GB 15 GB 15 GB
Secure Web Forms
Monthly form submissions Unlimited Unlimited
Maximum pages per form Unlimited Unlimited
Ready-made form templates With add-on Included Included
Calculated questionnaires (e.g. PHQ-9) With add-on Included Included
Design your own forms With add-on Included Included
Receive form submissions as PDFs With add-on Included Included
Conditional field visibility With add-on Included Included
Share forms with colleagues Not included Included Included
Electronic Signatures
Sign on desktop and mobile Not included Included Included
Detailed activity records Not included Included Included
ESIGN and UETA compliant Not included Included Included
One signer per form Not included Included Included
Multiple signers per form Not included Not included Coming soon
Private Message Center
Maximum clients per month Unlimited Unlimited Unlimited
Clients can send secure replies Included Included Included
Clients can sign in with their Google, Apple, or Microsoft account Included Included Included
Customization & Branding
Custom logo Not included Included Included
Custom secure web form accent color Not included Included Included
Remove Powered by logo from forms Not included Not included Included
Customer Care
One-on-one setup assistance by phone Included Included Included
Technical support by phone and email Included Included Included
Online knowledge base Included Included Included
Security & Compliance
Email archiving Included Included Included
Two-step verification Included Included Included
Encryption OpenPGP & SSL OpenPGP & SSL OpenPGP & SSL
Domain Administration (if using a custom domain)
Standard email forwarding Included Included Included
Catch-all email forwarding Included Included Included
Manage user accounts Not included Included Included
Expand all features

All prices displayed are in US dollars. Taxes may apply. Full refund if you cancel within 60 days.

Hushmail for Personal Use includes Encrypted Email and a Private Message Center, with an email address ending in , , , or . Custom email domains are not available on this plan.

The price displayed is in US dollars. Taxes may apply.

From the Blog

HIPAA technical safeguards explained for your small practice

Published on November 29, 2024

This guide simplifies HIPAA technical safeguards with easy-to-implement steps for small practices. Read more.

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