Prescription For Therapeutic Phelbotomy

Form Template

This mobile application helps users fill out Prescription For Therapeutic Phelbotomy.

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Users can enter patient information (e.g. Name, Date of Birth, Medical History, etc..) as well as the patient Dx. Additionally, the app lists important information for patients and physicians. This includes that prescriptions must be renewed yearly, patients with the diagnosis of Hemochromatosis will not be charged a fee for the service regardless if they meet standard donor criteria, and more. Physicians can enter their name and sign off. Use this app for any Prescription For Therapeutic Phelbotomy procedures or customize this app to fit your own procedure. This app will create a PDF that will be emailed to the user and uploaded to the GoCanvas Cloud where you will have full access to any and all data submitted.

  • Signature Capture
  • Conditional Fields
  • Submission Editing
  • Reference Data
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  • iPhone
  • iPad
  • Android
  • Windows
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  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
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“I’m not a tech guy and I was able to pick this thing up in probably an hour, and actually start to build apps. I’ve done them over lunch when I’ve gotten frustrated with a process that didn’t exist in our company. So for non tech people who’ve got a problem, the support here is awesome and I’d recommend it to anybody, not just in our industry.”

Dave Kramer, PennLine Service

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