Acid reflux intake that captures symptom frequency and red-flag signs up front
Patients report symptom frequency, flag red-flag symptoms like difficulty swallowing or vomiting blood, and share prior treatments and GERD history before uploading their medication list, so you see appointment-ready cases first.
Preview your acid reflux intake
Explore 6 questions from the Acid Reflux template. This interactive preview uses illustrative scoring and sample attachments. Open the full survey to try the complete intake.
What a qualified acid reflux lead should tell you
Intake for patients seeking evaluation of acid reflux symptoms, covering symptom frequency, warning signs, prior GERD or hiatal hernia diagnosis, and treatments already tried before a gastroenterology consultation.
- Often Experience Acid Reflux
- Noticed Difficulty Swallowing, Unexplained
- Previously Been Diagnosed With
- Treatments Have Already Tried
- Able Attend In-Person Appointment
- Soon Be Seen
The questions your team needs answered
Every acid reflux intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| How often do you experience acid reflux symptoms? | Daily or frequent symptoms indicate a more persistent case that likely needs provider evaluation sooner than occasional reflux. |
| Have you noticed difficulty swallowing, unexplained weight loss, or vomiting blood? | A yes here can indicate a complication beyond routine reflux, so it carries the highest weight and should route for priority review. |
| Have you previously been diagnosed with a condition related to acid reflux, such as GERD or a hiatal hernia? | A prior GERD or hiatal hernia diagnosis tells your team whether this is a new workup or a continuation of existing care. |
| What treatments have you already tried for your symptoms? | Knowing which treatments have already failed helps the provider avoid recommending options the patient has already tried. |
| Are you currently able to attend an in-person appointment with a gastroenterology provider? | A no answer signals the patient may need a telehealth path rather than a booked in-office slot. |
| How soon are you hoping to be seen? | Desired timing helps your front desk prioritize scheduling calls without changing the clinical urgency score. |
How Cliont scores acid reflux leads
Configured answer weights help your team prioritize follow-up. Your team reviews each submission and decides the next step.
Value signals
- Daily
- A few times a week
- A few times a month
- Noticed Difficulty Swallowing, Unexplained: yes
- Able Attend In-Person Appointment: yes
See an example lead handoff
Illustrative lead details and score show how a submission can reach your team.
Acid Reflux Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for acid reflux workflows
| Cliont capability | Acid Reflux application |
|---|---|
| Weighted answer scoring | A yes on difficulty swallowing, weight loss, or vomiting blood automatically raises the lead's score above routine daily-frequency reflux cases. |
| Multi-select intake fields | Captures which treatments a patient has already tried, so your team can skip repeating antacid or lifestyle advice already attempted. |
| Availability-based routing | The in-person appointment availability answer lets you separate patients likely to need telehealth from those ready to book in office. |
| CRM delivery | Completed reflux intakes, including symptom frequency and GERD history, are sent directly to your CRM instead of sitting in a shared inbox. |
Example acid reflux lead scenarios
Illustrative situations explain the intake questions and possible follow-up.
Daily reflux with alarm symptoms
Patient reports daily symptoms and answers yes to difficulty swallowing or vomiting blood, which the intake flags for priority review ahead of routine daily-reflux cases.
Long-standing GERD, treatment failing
Patient has a prior GERD diagnosis and has already tried prescription medication without relief, signaling a case that needs provider-level evaluation rather than lifestyle advice.
Occasional symptoms, just researching
Patient selects rare symptoms and 'just exploring options' for timing, which the intake surfaces as lower urgency without discarding the lead.
New patient, no treatment tried yet
Patient has never tried antacids or lifestyle changes and wants to be seen within a week, indicating a first-time workup rather than an escalation of failed treatment.
Cannot attend in person
Patient answers no to in-person appointment availability, prompting your team to consider telehealth routing before a slot is offered.
Connect Cliont to your workflow
Connect your CRM
HubSpot, HighLevel, monday.com
Connect your legal software
Lawmatics, MyCase, Clio Manage and Clio Grow
Notify your team
Email, SMS, Slack
Configure other destinations
Google Sheets, configured webhooks, Zapier and API workflows
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More gastroenterology intake templates
Acid Reflux lead-intake FAQs
How does the intake flag patients who might need urgent evaluation?
The question about difficulty swallowing, unexplained weight loss, or vomiting blood carries a high weight, so a yes answer surfaces the lead as high priority regardless of how often symptoms occur.
Does the intake distinguish new patients from those already diagnosed with GERD?
Yes, the intake asks whether the patient has a prior diagnosis such as GERD or hiatal hernia, so your team can separate first-time workups from follow-up or treatment-failure cases.
What happens if a patient can't come in for an in-person appointment?
The intake captures in-person appointment availability directly, so you can identify patients who may need a telehealth option before offering a slot.
Does the intake track what treatments a patient has already tried?
Yes, patients select from over-the-counter antacids, prescription medication, lifestyle changes, or none yet, giving your team context on treatment history before the first visit.
How is symptom frequency used in scoring?
Daily or frequent symptoms score higher than rare episodes, helping your team prioritize patients with more persistent reflux over those with occasional or mild symptoms.
How is this different from the Digestive Symptoms or Abdominal Pain intake?
This intake is scoped to acid reflux specifically, asking about frequency, alarm symptoms, and GERD history rather than the broader symptom triage used for Digestive Symptoms or Abdominal Pain.
Turn acid reflux visitors into qualified patients
Give every acid reflux visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.