The demo
See both sides of the form.
Fill in a real Secure Form intake the way your patients will, then open the PDF your office would receive. It takes about three minutes.
On a phone? Scan to open it there.
No account, no email. Please use made-up details; nothing you type leaves your browser.
Cove & PineFamily Dentistry
New Patient Intake
Step 1 of 6 · About you
First nameLast nameDate of birthPhone Fill with sample dataCove & Pine Family DentistrySample
New Patient Intake
Patient information
- Name
- Alex Sample
- Date of birth
- 04/12/1988
- Phone
- (617) 555-0123
- Address
- 42 Sample Lane
Medical history
What your patient fills in What your office receives
How the demo works
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Be the patient
Answer the questions yourself, or press Fill with sample data to fill in every answer at once.
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See what your office gets
Press View sample PDF at any step. It opens right on the page, ready to view and download.
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Then send us yours
We build the form you use today the same way, and you try it just like this one.
Built for made-up details.
This demo is public, and there's no Business Associate Agreement behind it. So we built it to keep everything you type in your browser, made the sample PDF from our own made-up patient, and switched off file uploads.
Why we built it this way
Any form on the open internet can be sent a real patient's health information. A live Secure Form runs under a Business Associate Agreement with your practice, with your records encrypted and kept apart from every other practice's. A public demo can't offer that.
So rather than ask you to be careful, we made the demo so there is nothing to be careful about. Your answers never leave your browser, nothing you type is sent to us or kept, and the PDF is laid out as your office would receive it, filled in with our sample patient.
Next, your own form.
Send us the form your patients fill in today, up to two pages. We'll build it as a working online form at no charge, and you can try it from start to finish, just as you tried this one.
When you're ready to use it with real patients, choose a service plan and sign a Business Associate Agreement with us.
Rather talk it through first? We're glad to.