Example HIPAA Integrated Form

Below, you’ll find an example of an integrated form that could be used to capture new patient information. Patient information is securely captured and results are sent via TLS to the email address of your choice, in the format of your choice.

Feel free to test out this form. We’ve changed the format for this testing purpose, so that whatever email address entered in the “Email Address” field will be the email address where form information is sent. Multiple formats will be provided for examples of formats.

NOTE: that form is for demonstration purposes only. Please do not use actual patient information in this form!

Integrated HIPAA certified form

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