Secure Online Patient Forms

Using a secure website form to protect confidential information:

Using our Secure online patient form service you can collect confidential information including PHI of visitors/patients from your website with 256-bit SSL encryption and HIPAA compliance. No scripts or certificates to install for your website on your server.

A secure online form is necessary to collect Protected Health Information (PHI) and other sensitive, private information such as social security details, credit card details, legal information, etc. Encrypted and secure web form is not only mandatory to collect PHI but also gives confidence to the visitors of your website.

Free designing and configuring of form: Don't waste your valuable time in designing and configuring. We do that for you. No extra charges!! Just select the design from samples, inform us the fields required by you. We will design, configure, host the form, and provide you with the link. Just a monthly flat fee for secure hosting.

HIPAA Compliant Secure Patient Forms Online

MD OfficeMail can build Secure, HIPAA Compliant Webforms that can be linked to your website. Patients can fill out these forms securely and transmit information to your office.

We build following forms:
• Patient Questionnaires
• Patient Consent Forms
• Contact Us Forms
• Authorization Forms

How MDofficeMail Secure contact Form works

When a visitor to your website clicks the form link in website or email a secure form opens which is a HIPAA compliant. This is a web page in our secure server in which the information will be entered by the patient.

Once the completed form is submitted, all the collected information is converted into an email message and sent to the secure MDofficeMail email account that is associated with the secure form. Filled in form can also be delivered as a .pdf or .xls document.

Features of MDofficeMail Online Secure Form
  • Secure and HIPAA compliant
  • Filled in form can be delivered as a . pdf document. Very userful in case of consent forms, authorization forms etc
  • Highly customizable to match your website.
  • Customized fields as per your requirement including text fields, drop-down menu, check boxes, radio buttons etc.
  • Sub-menus with conditional display can be configured.
  • Responsive. The size of the screen displaying the form is detected and the design is customized for that specific device..
  • Attachments can be sent.
  • Forms can be signed online with real signature.
  • No installations to be made in your website except adding the hyperlink. No certificates and no hassle.
What is the cost of Secure contact form?

Each customized secure web form costs starting from $ 7/mo. You need to have MDofficeMail email account to receive submitted information. No designing or setup charges for forms with 10 or less fields.

Can I see a sample Secure contact form?

Click here to see a sample Secure contact Form. It is live. You can fill and submit it to see the functionality. 
More samples are here:Sample-1, Sample-2, Sample-3, and Sample-4,

What is needed to be done to have Secure Contact Form for my website?

It is very easy!

  • Go to subscriptions/orderservices.aspx and place order
  • Send details of fields and text required in the form.
  • Send header and other images used in your website to be incorporated in the form
  • Allow 4-24 hours for us to complete the process and send you the hyperlink code
  • Hyperlink “Contact Us” or any other appropriate button in your website.

30-day refund policy

Plans & Price


MDVault helps to send HIPAA-compliant, encrypted messages to any recipient, for end-to-end protection..



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