Available on

Apple Android Windows

Healthcare Surge: Charge Capture Form Mobile App

The Healthcare Surge: Charge Capture Form presented is to be used to capture charges for service, medication, and supplies for individual patients during a healthcare surge and was developed from the suggested minimum data list for charge capture. MyCanvas allows GoCanvas users to now share documents with their customers

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

Want to learn more about GoCanvas?

Request a Demo

Take a peek inside the Healthcare Surge: Charge Capture 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.'}}

  • {{data.title}}

Included Fields

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

  • Ico textbox

    Patient Name (Last, First):

  • Ico textbox

    Unique Patient Identifier (#):

  • Ico textbox

    Provider Name:

  • Ico textbox

    Disaster Incident Number:

  • Ico textbox

    Service Description

  • Ico textbox


  • Ico integer

    Units of Service or Quantity

  • Ico date

    Date of Service

  • Ico statictext

    To be completed by Billing

  • Ico dropdown


  • Ico decimal

    Service Price

  • Ico calculator

    Posted Charge

  • Ico summary

    Total Charges

  • ...and More!

Related Health Care & Social Services Apps... and they're all free for GoCanvas subscribers!

App Name

Site Security Inspection for Sports a...

If you are responsible for the management and maintenance of sporting and recreational facilities Site Security Inspection...

App Name

Hospital Pandemic Influenza Readiness...

Planning for pandemic influenza is critical for ensuring a sustainable healthcare response. The Hospital Pandemic Influenz...

App Name

HIPAA Response to Patient Request to ...

Tip sheet that includes information on how to use the form, relevant HIPAA definition, penalties for noncompliance, helpfu...

App Name

Business Security Checklist (Australia)

This app walks you through a generic business security check, helping you to assess potential security risks. Easily amend...

App Name

Letter to Creditor on New Account

Write a letter to each creditor where an account was opened or used in your name. Repeat what you said in your telephone c...

App Name

Security Officer Performance Plan and...

Security guards are responsible for handling security incidents in a professional manner. It is critical that security gua...

App Name

Site Safety & Security Assessment For...

This Site Safety & Security Assessment Form covers information such as: Are exit routes clear of all obstruction inte...

App Name

Patient Consent & Authorization for R...

Use this attorney-reviewed form to meet your HIPAA obligations. HIPAA requires covered entities to obtain an individual’s ...

More Information