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Form Template

This electronic form is designed so that a tablet or smartphone can replace the forms that are used to collect customer contact information, personal insurance information, and all of the details of the items provided with the proper codes.

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It creates a PDF that can be stored for records as well as downloading the data onto a spreadsheet. It can even be used as a template to customize a dynamic form for a healthcare provider.

Note; Whenever health Information is collected, proper security measures must be taken. With proper procedures this electronic form can collect and store all your data in compliance with HIPAA regulations. For more information on customization and complying with privacy regulations, please contact us at

  • Signature Capture
  • Image Capture
  • Conditional Fields
  • Submission Editing
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  • iPhone
  • iPad
  • Android
  • Windows
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  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
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*The Capterra SoftwareAdvice ​and GetApp logos are a service mark of Gartner, Inc. and/or its affiliates and is used herein with permission.*

Don't take our word for it...

“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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