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Wordpress hosted online medical intake forms - repost

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.


-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.

Compétences : Formulaires électroniques, HTML, Design de site internet, WordPress

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Concernant l'employeur :
( 11 commentaires ) Los Angeles, United States

Nº du projet : #4146005

22 freelance font une offre moyenne de $221 pour ce travail


Freshwebsites is a design and web development company, technology services and branding company. Combining unparalleled experience, comprehensive capabilities across the design and development industry and business fun Plus

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 25 jours
(26 Commentaires)

We can get this done for you

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 10 jours
(206 Commentaires)

!!!!!!!!Hi, ONE STOP Company for PHP, WORDPRESS, SEO and WEB DESIGN. Open message board for discussion & previous work. We are a team of PHP, WORDPRESS developers and web designers who are in this field since last 10 y Plus

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 7 jours
(58 Commentaires)

Our goal is to exceed the expectations of every client by offering outstanding designs, increased flexibility, greater value in development, thus optimizing system functionality and improving operation efficiency. Our Plus

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 20 jours
(18 Commentaires)

Hi, Have Gone through your details. We have left a PMB for you plz have a look over there. Thnx Jay JS Infoway Team

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 8 jours
(123 Commentaires)

Great day sir.. we can assist you for an optimum cost. Thanks.

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 10 jours
(117 Commentaires)

*******Dear Sir, We are experts with similar expertise to your project requirement. We are very much interested & eager to provide professional and quality service for you. Please check private message to discuss furth Plus

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 8 jours
(59 Commentaires)

Hi Have Gone through your requirement and understood, we are very sure that we can do your needs with your entire satisfaction. We have left a PMB for you plz feel free to have a look over there. Thnx Ram Webzin I Plus

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 7 jours
(79 Commentaires)

hi, please find the attached document and private message ...Thanks!!!

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 15 jours
(74 Commentaires)

Dear Sir, Please check your inbox. Best Regards.

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 3 jours
(42 Commentaires)

Hello, Review your project details and we are ready for your [login to view URL] check your Private message box. Thanks Softtonix Team

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 15 jours
(27 Commentaires)

Hi, We can develop the website of your choice. Please refer to the message board for more details. Best Regards, Paramita

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 7 jours
(20 Commentaires)

I have review project details and have gone through your requirements and would like to discuss further regarding the project with you. Looking forward for a long term business relationship.

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 10 jours
(42 Commentaires)

Hi, Experts team of SEO/Wordpress/PHP/joomla/Drupal developers and designers. Please check PM for detail. Thanks, Gaurav

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 10 jours
(34 Commentaires)

Please check PMB

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 5 jours
(18 Commentaires)

Please attached the document so that I can proceed further

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 2 jours
(11 Commentaires)

Dear Sir, I do have 9 years for experience in wordpress and have built over 200+ wordpress [login to view URL] let me know if we can work [login to view URL] awaiting your response.

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 3 jours
(26 Commentaires)

We are interested. Please check your private message.

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 2 jours
(11 Commentaires)

We are a quality web design and web development firm offering affordable services to our clients. We can complete the project in 10 days as we have an expert team of professionals with more than 8 yrs experience in the Plus

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 10 jours
(4 Commentaires)

Experienced Wordpress developer and PHP programmer. Background in neuroscience too.

%bids___i_sum_sub_35% %project_currencyDetails_sign_sub_36% USD en 10 jours
(10 Commentaires)