2 minutes to complete
This is a medical release form. This medical release form will allow you to authorize another person to receive medical information about you from your healthcare provider.
Please complete the following questions to the best of your ability. If you have any questions, please feel free to ask your provider or call our office.
Why are you seeking medical treatment at this time?
Have you ever been diagnosed with any medical conditions? If so, please list them.
Do you have any allergies? If so, please list them.
Are you currently taking any medications? If so, please list them.
Have you ever had any surgeries? If so, please list them.
Do you have any family history of medical conditions? If so, please list them.
Do you have any personal history of medical conditions? If so, please list them.
Are you pregnant or nursing?
Do you have any other medical conditions that we should be aware of? If so, please list them.
BlockSurvey puts privacy and security above anything else. The integration of blockchain technology is not a gimmick as in many products; it's a core feature enabling privacy and security. The survey building tools are impeccable. I've used numerous SaaS survey tools, and nothing comes close.
This platform goes far beyond basic surveys. I’ve used it for lead generation, landing page enrichment, and even embedded videos. Everything’s easy to use, well documented, and super flexible—whether you're building forms, quizzes, or something more advanced.
Uses blockchain technology that allows users to create survey forms where data is secure and private. UI looks very beautiful.
For our NGO, data privacy is everything—and this platform nails it. It keeps personal info fully protected while letting us design beautiful, chat-like surveys that increase engagement. Team collaboration features sealed the deal.
From blockchain-level security and AI-generated questions to powerful logic flows and white-label domains, BlockSurvey has it all. It’s secure, innovative, and packed with features like calculations, templates, and in-app analytics. I use it to create personalized assessments for leadership training—nothing else compares.
BlockSurvey is very user-friendly with amazing customization options. It makes capturing data simple and secure. While the Web3 space still has room to mature, the platform itself is smooth and intuitive.
Creating surveys with BlockSurvey has been a breeze. The drag-and-drop interface is intuitive, and we’re able to collect data anonymously and securely—without intermediaries. It’s interactive, friendly, and encourages high participation while protecting user privacy. The reports are solid, and we’ve used it confidently for internal and external feedback.
Few tools combine data confidentiality and form aesthetics like this one. The conversational design improved my response rate by 43%, and the webhook integrations made syncing to our CRM effortless. I also love how responsive and community-driven the support team is.
I think BlockSurvey is good for short and long surveys. What I find the best is the fact that there are so many templates I can use and customize.
