Medium

Available on

Apple Android Windows

Colon Intake Form Mobile App

Your Colon and Rectal Surgical team needs to evaluate your health prior to surgery. The Colon Intake Form mobile app covers General Health, Referring Physician, Medications, Drug Allergies, Review of systems and Family History. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Colon Intake Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico date

    Date:

  • Ico textbox

    Name:

  • Ico date

    Date of Birth:

  • Ico multiline

    What are you here for today?

  • Ico textbox

    Referring Physician:

  • Ico textbox

    Phone:

  • Ico multiline

    Address:

  • Ico textbox

    Primary Care Physician:

  • Ico textbox

    Phone:

  • Ico multiline

    Address:

  • Ico multiline

    Please list anyone else that we may release medical information to:

  • Ico decimal

    Height:

  • Ico decimal

    Weight:

  • Ico statictext

    Please mark all that apply, however this section is optional:

  • Ico checkbox

    Hispanic or Latino

  • Ico checkbox

    Asian

  • Ico checkbox

    African-American

  • Ico checkbox

    Caucasian

  • Ico checkbox

    Native Hawaiian

  • Ico checkbox

    Native American or Alaskan Native

  • Ico checkbox

    Pacific Islander

  • Ico checkbox

    Other

  • Ico checkbox

    Unknown

  • Ico multiline

    Please list your current medications and dosages

  • Ico multiline

    Please list your past surgical history

  • Ico textbox

    Do you have any drug allergies?

  • Ico multiline

    If yes, please name the drugs and reactions:

  • Ico dropdown

    Review Item

  • ...and More!

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