Preventive Health Screening Reminder Enrollment

Preventive Health Screening Reminder Enrollment — Form Fields

This healthcare template includes 14 fields. Patients enroll in a preventive care reminder program for annual screenings and follow-up exams. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Email Address (email, required)
• Phone Number (text, required)
• Primary Care Provider Name (text, required)
• Preferred Contact Method (dropdown selection, required) — options: Email, SMS, Phone Call, Patient Portal
• Annual Wellness Exam (checkboxes, optional)
• Mammogram (if applicable) (checkboxes, optional)
• Colonoscopy (checkboxes, optional)
• Prostate Cancer Screening (if applicable) (checkboxes, optional)
• Bone Density Scan (checkboxes, optional)
• Blood Pressure Check (checkboxes, optional)
• Cholesterol Panel (checkboxes, optional)
• Remind me how far in advance? (dropdown selection, required) — options: 2 Weeks, 1 Month, 3 Months, 6 Months