Wordpress hosted online medical intake forms - repost

In Progress

NAPA Center is an intensive therapy clinic that specializes in pediatric neurological disorders. I would like to start to convert all our patient records to electronic format and would like to add all the necessary forms/paperwork to be hosted on our website [url removed, login to view]

The site was built with wordpress and I've found many online forms that are simple enough to add to our site myself, but not complex or professional enough looking to use. I'll try to explain in specifics what we would like below, but we are open to suggestions and ideas.

*We would like an initial screen with a few drop down menu questions to filter what type of patient they are (different patients require different types of paperwork). Also would like to give options of what language they would like the forms in(english & espanol). We would like to additionally add a separate section below for credit card info info to be entered and sent to our billing department.

*Once they specify the type of patient either a pop up window or next page displaying their necessary paperwork. I would like to paperwork to be displayed as 3-4 different sections(patient records, patient history, insurance info, release forms, etc.) The release forms are what we would need the electronic signatures to be used for.

*Once the paperwork is complete and they submit I would like it to be sent to an e-mail address with each sections as a different .pdf attachment.

Requirements

-Electronic signatures

-Ability to be sent to an e-mail

-Professional looking while matching current websites theme

-Ability for myself to change or add as needed.

-Ability to upload copies of insurance cards

*I'll spell out everything I would like in an outline including attachments with all necessary text and what type of input for each question. You'll be creating the forms and basically copy and pasting everything I give to you into them. Like I previously mentioned i'm very open to suggestions and ideas to make this project work. If you are unable to complete any of the above please let me know prior to bidding.

Skills: Electronic Forms, HTML, Website Design, WordPress

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Project ID: #4146005

22 freelancers are bidding on average $221 for this job

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nmans

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Msolutions7

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jsinfoway

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6.7
graphicaa

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(117 Reviews)
6.7
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webzin

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6.1
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6.0
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5.9
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raiseit

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neurotech1

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