For clinics & practices · US
An online patient intake form built for PHI
Collect demographics, medical history, insurance, and consent before the first visit — in a branded form where the submission is encrypted in the patient’s browser and your practice holds the only key.
Northside Family Health
New patient intake & medical history
Full name and date of birth
Home address and phone
Insurance carrier and member ID
encryptedReason for visit
Current medications and allergies
encryptedPast medical and surgical history
encryptedFamily history
encryptedConsent to treat and privacy acknowledgment
Fields marked are encrypted in the browser before this form is sent.
The problem this solves
Paper intake on a clipboard is slow and error-prone. Emailing a PDF is worse: Protected Health Information ends up in inboxes and download folders with no access control and no audit trail.
A general-purpose survey tool is not an answer either — most will not sign a Business Associate Agreement for the account you actually use.
Why the encryption matters here
Every intake response is encrypted in the patient’s browser with RSA-3072 and AES-256 before it is transmitted. The key is generated client-side and never reaches VerifID, so the platform, its staff, and anyone who breached it see only ciphertext.
That collapses the set of people who can read PHI down to your own care team — which is what the HIPAA Security Rule’s access-control expectation is really about.
HIPAA: How the architecture maps to HIPAA technical safeguards, and how the BAA works. Read more →
How it works
- 1
Brand and configure
Add your practice logo and the intake fields you use today. Sign the BAA on an eligible plan.
- 2
Send before the visit
Text or email the form link when the appointment is booked. Patients complete it on any device.
- 3
Decrypt at the front desk
Open submissions with your practice key. Data lands in your workflow; nothing was readable in transit.
Frequently asked questions
Will VerifID sign a BAA for patient intake? ▾
Yes, on eligible plans. You must have the BAA in place before collecting Protected Health Information through the form.
Can practice staff or VerifID read intake submissions? ▾
VerifID cannot — the decryption key never leaves your control. Within your practice, access is limited to the people you authorise, and each decryption is logged.
Does the patient need an account or app? ▾
No. The form opens in a browser and encrypts the response in the page before sending. Patients just fill it in and submit.
How is this different from a HIPAA-compliant survey tool add-on? ▾
Most tools encrypt data at rest with keys they hold, so the vendor is still inside your access boundary. Here the encryption is client-side and the key is yours, so a platform breach exposes nothing readable.
Build this form for your organisation
Start on the free plan, add your branding, and publish an encrypted version in minutes.