Patient Intake App
Sign in
Patient Intake App - Add Patient
 
For which table?
Patient Intake Forms
Cancel

Open
Open in New Window

We are updating our Terms of Service. See our blog post highlighting the changes. By continuing to use the Quickbase Service, the new Terms of Service will become effective on the renewal date for each account that you manage. If you do not accept the changes, please notify us thirty days in advance of your renewal date.
Quickbase will send a report of the events currently displayed on your calendar.
New apps will be added to your account close
close
Create your own free Quickbase app
Quickbase Exchange has hundreds of free apps for any business process.
It's simple to get started and you don't need to be technical to do it.
  • Project Management
  • Customer Support
  • Sales & CRM
  • Marketing
  • Team Management
  • Human Resources
  • Information Technology
  • Industry-specific solutions
Find an app in Quickbase Exchange
close
We need to check with your admin first...
We know you're eager to create your first app-but your account settings don't let you create apps yet. We've asked your account admin to allow it, and you'll get an email from us when you can.
Prefer a more hands-on solution? Can't wait? Try a 30-day free trial, and get started creating apps immediately.
Build a new app from scratch Import a spreadsheet to create a new app
Start a trial
Quickbase is a web-site that lets you select, customize, and share online workgroup applications. The application you are using right now is powered by Quickbase.

Chances are that your organization has purchased the Quickbase service, in which case you might be able to build and deploy your own web application for little or no additional cost.

You have permission to create your own web applications.

To find out more about Quickbase, visit our web site.

Terms of Service



For which table?

Patient Intake Forms
  • From scratch
    Design your own table
Patient Intake Forms

Add Patient

Save & close Cancel
Create a new Quickbase user by entering his/her email address, first name, and last name below:

Email address:
First Name:
Last Name:
  • Save & close
  • Save & new
  • Save & close
  • Save & new
Prev | Next

0
For English, Click here
Formulario de registro de pacientes nuevos de CHC
Datos del paciente
 *
 *
 *
 *
 *
 *
Por favor, ingrese su dirección de correo electrónico
 *
 *
ext.
 *
 *
 *
 *
 *
 *
 *
 *
 *
 *
 *
 *
 *
 *
Determinantes sociales de la salud (DSS)
Si está buscando soporte, complete el siguiente conjunto de preguntas para que podamos determinar la mejor manera de brindarle soporte.
Si desea ayuda con alimentos, vivienda, seguro, transporte u otras necesidades, puede comunicarse con 211 marcando 211 desde un telefono o visitando www.211ct.org.
Informacion del guardian
 
El Garante es la persona a la que se le deben enviar los estados de cuenta.
 *
 *
 *
 *
 *
 
Por favor, ingrese su dirección de correo electrónico
 *
 *
 *
 *
Datos de contacto en caso de emergencia
 *
 *
 *
 * ext.
 *
Por favor revise los siguientes document
Por favor, haga clic en el boton Términos y condiciones. para revisar nuestras políticas con respecto a su informacion personal de salud

Al firmar y fechar a continuacion, reconozco que he leído los documentos anteriores y he recibido una copia de Términos y condiciones.
 
 *
 *
Por favor, haga clic en el boton Aviso de Practicas de Privacidad (NPP) de CHC. para revisar nuestras políticas con respecto a su informacion personal de salud

Al firmar y fechar a continuacion, reconozco que he leído los documentos anteriores y he recibido una copia de Aviso de Practicas de Privacidad (NPP) de CHC.
 
 *
 *
Informacion del proveedor de atencion me
CHC desea recopilar su historial medico e informacion anteriores. Al completar una ROI (una divulgacion de informacion) a continuacion, usted puede autorizar a CHC a OBTENER su informacion de su anterior consultorio de atencion medica
 *
ext.
ext.
Guardar y cerrar
Firma de liberacion
Entiendo que tengo el derecho legal de revocar esta autorizacion en cualquier momento/ Entiendo que si revoco esta autorizacion, debo hacerlo por escrito y presentar mi revocacion por escrito al Departamento de Registros Medicos de Community Health Center, Inc. (CHC) Departamento de Registros Medicos. Entiendo que la revocacion no se aplicara a la informacion que ya ha sido divulgada en respuesta a su autorizacion. Entiendo que la revocacion no se aplicara a mi compania de seguros cuando la ley le otorgue a mi aseguradora el derecho de impugnar un reclamo bajo mi poliza.

Entiendo que una vez que se divulgue la informacion anterior, el destinatario puede volver a divulgarla y la informacion puede no estar protegida por las leyes o reglamentos federales de privacidad.

Entiendo que autorizar el uso o la divulgacion de la informacion identificada es voluntario. Puedo negarme a firmar esta autorizacion. No es necesario que firme este formulario para garantizar el tratamiento sanitario. Puedo ponerme en contacto con el Responsable de Privacidad si tengo preguntas sobre mi informacion sanitaria.

Entiendo que al ingresar mi nombre a continuación, estoy firmando esta Autorización electrónicamente. Acepto que mi firma electrónica es el equivalente legal de una firma manual en esta Autorización.
Al firmar abajo, reconozco que he leido y entendido este formulario de autorizacion y que CHC tiene 30 dias para cumplir con mi solicitud.
 
Admin
Show fields from Show fields from Show fields from a related table
 
 
 
 
 
 
Don't show me this message again

 

Can I annotate fields to indicate their intended use?

Yes. You can provide "Help" to your users for any field:

1. On any page in your application, click "Customize" then "Fields". If it is a multi-table application, select the table.

2. Click the "Edit" button next to the field for which you want to add an annotation.

3. In the "Help" text input box, enter text that will assist your users, and click "Save".

Your text will appear when the user hovers over or clicks on the question mark icon next to that field on the Add Record and Edit Record pages.
 
foo

We're glad you're interested in doing more with Quickbase!

Now we need to make you official before you share apps or manage your account.

Verifying your email lets you share Quickbase with others in your company.

Your work email
Your company
Client Performance Report
Network latency: ()
The time taken for page load once the page is received from the server:()
The total process of navigation and page load: ()

From inline js at page top..
        .. to the time until docready:( s)
        .. to the time until window load begins: ( s)
        .. to the time until window load ends: ( s)
  • User profileProfile
  • Sign up linkSign up now
  • Manage realmManage
  • LogoutSign out
  • This app
  • Patient Intake App
  • Your role is EOTI
  • Switch accounts
  • {{firstServiceAccount.FirstName}} {{firstServiceAccount.LastName}} (Service)
    {{firstServiceAccount.Email}}
  • {{secondServiceAccount.FirstName}} {{secondServiceAccount.LastName}} (Service)
    {{secondServiceAccount.Email}}
  • More accounts
    • {{serviceAccount.FirstName}} {{serviceAccount.LastName}} (Service)
      {{serviceAccount.Email}}
You've made changes to this Patient. Do you want to save these changes before going to the next screen?
Report Name *
Description
Reports and Charts Panel
Each table has a panel listing its reports and charts, organized in groups.
Please wait while your new report is saved...
Print the report as a table
Print one Patient per page ( total)
Using the form:
Print as much of the timeline as fits on a single page
Print the timeline over multiple letter-size pages in landscape orientation
  • New subscription...
  • Print
  • Search & replace in this report...
  • Save as a spreadsheet
  • Clear New and Updated flags
  • Sorting & grouping...
  • View as a calendar
  • View as a timeline
  • Change the owner of these records...
  • Delete all records in this report
  • Show the expanded URL for this report
  • Report
  • Group up Group down
    Hide this column Add a column...
    New table based on this column...
    Column properties... Field properties...
    grouping by
    Field label
    Column heading override
    Justification
    What does auto mean?
      Multiple values found.   more...
    Fields in:

    Fields to Extract:

    Name for the new table:
    Items in the new table are called:

    When you bring additional fields into a conversion, Quickbase often finds inconsistencies. For example, say you're converting your Companies column into its own table. One company, Acme Corporation, has offices in New York, Dallas and Portland. So, when you add the City column to the conversion, Quickbase finds three different locations for Acme. A single value in the column you're converting can only match one value in any additional field. Quickbase needs you to clean up the extra cities before it can create your new table. To do so, you have one of two choices:

    • If you want to create three separate Acme records (Acme-New York, Acme-Dallas and Acme-Portland) click the Conform link at the top of the column.
    • If the dissimilar entries are mistakes (say Acme only has one office in New York and the other locations are data-entry errors) go back into your table and correct the inconsistencies—in this case, changing all locations to New York. Then try the conversion again.

    Read more about converting a column into a table.


    Cut
    Copy
    Paste
    Paste Special

    Fill Down
    Reset to Original Values

    Insert Blank Rows
    x
    x

    Undo

    Edit this Field's Properties...
    x
    x

    Editing Conflict
    you changed ' '
    from:
    to:
      changed ' '
    from:
    to:

    To Paste

    To paste clipboard data that comes from another program right-click on the text area below, select Paste, then click OK.
    Unable to Save Changes
    While you were editing these records, someone else was also editing some of the same records and made changes that conflict with some of your changes.
    Unable to Save Changes
    You are no longer signed in to Quickbase.
    Either your session expired or you signed out in another browser window.
    Please sign in below and then click the Save Changes button again.
    Sign in failed. Please try again.
    Email address (or user name):
    Password:
     
  • Expand this section to show all related x
  • Collapse this section and make it scrollable
  • Clear "New" and "Updated" Flags for all x