S e c u r e   P a t i e n t   F o r m s  -  D e m o
This is a live, interactive Demo using an Eye Care Professional form. (The forms are personalized, so your form will have your own pertinent health questions and patient information as you direct.)

We design the patient forms to blend in with the look and feel of the client's web site so that the patient has a feeling of continuity, but you do not have to have a web site in order to use our Secure Patient Registration forms.

There are only three required fields (first and last name and either email address or phone number). Please use made up entries for the demo - we are not asking for real input - just to show you how it works. We can code your form to include as many required fields as you want. The Demo form has been partially filled out, but you can delete or change any of the fields you want to in order to see how the different responses come back to you in the printout.

Each time a patient submits a form, your office will receive an email notification with a secure link to retrieve the form. Any of the designated staff members can then log in to your account at SecureHIPAA.com and download the information. In the interest of time, we are skipping these two steps in the demonstration.

You will have a secure Control Panel and you will have up to five usernames and passwords for your account (more are available if needed). The Administrator should use the 'main username and password' and not share it with any other members of the staff. The Administrator can log in to the Control Panel and assign usernames and passwords to staff members who will be authorized to retrieve the completed patient forms and to view all patient forms submitted. The Administrator can also change passwords and specify one or more email addresses where notifications for completed forms are to be sent.

There is more complete information available in our FAQ at SecureHIPAA.com
We can code any fields you choose to 'alert'. This form has been coded to 'alert' for the reason for the visit, general allergies, allergies to medications, and infectious diseases. The patient's responses to 'alert' fields are shown in red and the font is larger so that you can pick them up at a glance on the screen or when printed.

Click here to begin the Demo