Skip to content

Healthcare and wellness

Patient registration with signature

Three steps: details, medical history, then an ID upload and a signature on the consent. This form uses FillKite Pro.

PRO · Multi-step · File upload · Signature

Pro demo

Patient registration with signature

Fill it in and press the button to see how it behaves. Nothing you type is saved or sent.

Get FillKite Pro
Download this form

Test mode: you can try this form, but nothing you send is saved or passed on.

Your name

Medical history

Conditions
Do you take medicine every day?

Consent

A photo of your IDDrop files here or choose a fileDemo: uploads are switched off here. On your site this field accepts images and PDF files, up to 3 MB each.
Sign here

What is in this form

  • Your name (required)
  • Email (required)
  • Phone
  • Date of birth (required)
  • Conditions
  • Do you take medicine every day? (required)
  • Which medicines? (required)
  • Sign here (required)

How the conditional logic works

This form shows or hides fields as people answer, so everyone sees only what matters to them.

  • “Which medicines?” appears only when “Do you take medicine every day?” is “Yes”.

What FillKite Pro adds

This form uses multi-step, file upload, signature, which need FillKite Pro. You can try it here for free. The download works on a site that has FillKite Pro.

Questions

About this form

Is the patient registration with signature form free?

You can try it here for free. The form uses multi-step, file upload, signature, which need FillKite Pro, so the download works on a site that has FillKite Pro.

Is anything I type saved?

No. This demo runs in test mode: FillKite checks your answers like a real form, but nothing is saved and no email is sent.

How do I use this form on my site?

Install FillKite, download the form with the button on this page, then go to FillKite → Import → From a FillKite file and choose the file. After importing, open it in the builder, change anything you like and add it to a page.

Does this form use conditional logic?

Yes. 1 field or notice shows only when earlier answers call for it. “Which medicines?” appears only when “Do you take medicine every day?” is “Yes”.

What fields does it have?

It has 8 fields: Your name, Email, Phone, Date of birth, Conditions, Do you take medicine every day?, Which medicines?, Sign here.

More healthcare and wellness forms

Try another one.

Patient intake

Conditional logic. The questions change with the reason for the visit: symptoms for a new problem, a medicine name for a refill.

Try this form

Doctor appointment by department

Conditional logic. Each department asks its own question, and an urgent warning appears for chest pain.

Try this form

Vaccination booking

Conditional logic. Questions about pregnancy and earlier doses appear only for the people they apply to.

Try this form

FillKite Pro

Do more with every form.

FillKite Pro adds steps, uploads, live totals, quizzes, polls and more to the same builder.

See FillKite Pro
All form demos