Virtual primary care intake that asks what your team actually needs to
The intake captures the visit reason, confirms the patient is located where the provider is licensed, and checks device and video readiness — then collects a photo ID and insurance card before the appointment lands in your CRM.
The exact intake your virtual primary care leads complete
This is the real 6-question guided intake for Virtual Primary Care — the same flow your customers finish before you ever pick up the phone.
What a qualified virtual primary care lead should tell you
A remote video or phone visit with a primary care provider for a new symptom, medication renewal, chronic condition follow-up, lab review, or general checkup — qualification hinges on the reason for the visit, whether the patient is in a state the provider can legally treat, and whether they have a working video device.
- Main Reason Virtual Primary
- Patient Located In Same
- This Visit
- Soon This Appointment
- Have Existing Primary Care
- Have Device With Video
The questions your team needs answered
Every virtual primary care intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| What is the main reason you need a virtual primary care visit? | The visit reason carries the widest weight spread in the catalog, separating urgent clinical needs from routine or administrative requests. |
| Is the patient currently located in the same state or country where the provider is licensed? | A 'no' answer here signals a possible licensing mismatch that should be resolved before any slot is confirmed. |
| Who is this visit for? | Segments the lead so you can route, price, and prioritize it correctly. |
| How soon do you need this appointment? | The timeline answer tells your team whether to prioritize the request into a same-day slot or a later opening. |
| Do you have an existing primary care provider who has seen you before? | Knowing whether the patient has an existing provider distinguishes a continuity-of-care visit from a new-patient intake. |
| Do you have a device with video and internet access for this visit? | A 'no' answer on device readiness means staff should switch the visit to phone before the scheduled time rather than during it. |
How Cliont scores virtual primary care leads
Every answer is weighted automatically — no manual review required.
Value signals
- New symptom or illness
- Medication refill or renewal
- Ongoing management of a chronic condition
- Lab results or specialist referral
- General checkup or health question
- Other reason
See the lead your team receives
Virtual Primary Care 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 virtual primary care workflows
| Cliont capability | Virtual Primary Care application |
|---|---|
| Location/licensing check | Flags patients whose answer to the same-state licensing question is 'no' so staff can catch it before confirming an appointment slot the patient isn't eligible for. |
| Conditional branching | Separates new symptom, medication refill, chronic condition, and lab-review visits into distinct paths so each lands in your CRM with the right context attached. |
| Device readiness check | Captures whether the patient has video and internet access, letting your team switch a visit to phone-only before the scheduled time instead of during it. |
| Third-party intake handling | Tags each submission as self, dependent, or another adult being cared for, so refill and symptom requests for a child aren't mixed up with the account holder's own record. |
Common virtual primary care lead scenarios
New symptom, needs care today
A patient selects a new symptom or illness and wants the visit today — the intake surfaces this as a high-value, time-sensitive request instead of a routine checkup.
Chronic condition follow-up
An established patient logs in for ongoing management of a chronic condition and confirms they already have a primary care provider on file, giving your team continuity context before the call.
Patient outside licensed state
The patient answers that they are not currently located in the state or country where the provider is licensed, which the intake flags before your team books a slot they can't legally fill.
Refill request for a dependent
A parent submits the intake on behalf of a child needing a medication refill, and the intake captures who the visit is actually for so the record isn't mistaken as a self-visit.
General checkup, no urgency
A patient selects a general checkup with no specific timeline — lower urgency than a new symptom, letting your team schedule it into open slots instead of prioritizing it.
Connect Cliont to your workflow
Send leads
HubSpot, HighLevel, Salesforce, JobNimbus
Book visits
Google Calendar, Outlook Calendar, Calendly
Notify your team
Email, SMS, Slack
Automate follow-up
Zapier, Webhooks, API
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 telemedicine intake templates
Virtual Primary Care lead-intake FAQs
How does the intake handle a patient who is outside the provider's licensed state?
The intake asks directly whether the patient is currently in the same state or country where the provider is licensed. A 'no' answer is flagged so your team can catch a licensing mismatch before booking a slot the patient isn't eligible for.
Can the intake tell whether a visit is for the patient themselves or a dependent?
Yes — the intake asks whether the visit is for the patient, their child or dependent, or another adult they care for, so the record is tagged correctly from the start.
Does the intake check that patients can actually do a video visit?
It asks whether the patient has a device with video and internet access. A 'no' answer lets your team offer a phone visit or troubleshoot before the appointment time is wasted.
How does the intake distinguish a new symptom from a routine medication refill?
The visit-reason question separates new symptom or illness, medication refill, chronic condition management, lab or referral follow-up, and general checkup into distinct options, each weighted differently so higher-need visits stand out in your CRM.
What happens if the patient doesn't have an existing primary care provider?
The intake asks whether the patient already has a provider who has seen them before, giving your team context on whether this is a new-patient visit or a continuity-of-care follow-up.
How is appointment urgency captured for scheduling?
Patients select how soon they need the visit — today, this week, within two weeks, or no specific timeline — so your team can prioritize same-day requests over open-ended ones.
Turn virtual primary care visitors into qualified patients
Give every virtual primary care visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.