Patient Intake Form

Installation

Variants

Schema

Type aliases exported from this item's source. Use these to shape the data you pass in.

interface PatientIntakeData {
  firstName: string
  middleName: string
  lastName: string
  preferredName: string
  dob: string
  biologicalSex: string
  maritalStatus: string
  phone: string
  email: string
  streetAddress: string
  city: string
  state: string
  zipCode: string
  emergencyName: string
  emergencyRelationship: string
  emergencyPhone: string
  chronicConditions: string[]
  hasAllergies: boolean
  allergyDetails: string
  currentMedications: string
  pastSurgeries: string
  primaryCarePhysician: string
  clinicPhone: string
  insuranceCarrier: string
  memberId: string
  groupNumber: string
  policyholderName: string
  policyholderRelationship: string
  frontCardUploaded: boolean
  backCardUploaded: boolean
  hipaaConsent: boolean
  treatmentConsent: boolean
  telehealthConsent: boolean
  signatureName: string
  signatureDate: string
  signerRole: string
}

Files installed (2)

• src/app/components/blocks/patient-intake-form/patient-intake-form.component.ts49.2 kB

  Copy

  // HIPAA-compliant new patient registration in a SectionCard: a 4-step Stepper (Personal
  // Information → Medical History → Insurance & Billing → Consent & Sign) with demographic
  // inputs, chronic-conditions checklist, allergy/medication textareas, carrier selection with
  // card-photo dropzones, HIPAA disclosures with an electronic signature stamp, and a
  // post-submission confirmation receipt. Port of the React block 1:1.
  import { ChangeDetectionStrategy, Component, EventEmitter, Input, Output, computed, signal } from '@angular/core'
  import {
    Activity,
    AlertTriangle,
    Building2,
    Calendar,
    Check,
    ChevronLeft,
    ChevronRight,
    CreditCard,
    Download,
    FileCheck,
    FileText,
    Lock,
    LucideAngularModule,
    Phone,
    RotateCcw,
    ShieldCheck,
    Stethoscope,
    User,
    UserCheck,
  } from 'lucide-angular'
  import { cn } from '@/lib/utils'
  import { UiBadgeComponent } from '@/ui/badge/badge.component'
  import { UiButtonComponent } from '@/ui/button/button.component'
  import { UiCheckboxComponent } from '@/ui/checkbox/checkbox.component'
  import { UiInputComponent } from '@/ui/input/input.component'
  import { UiLabelComponent } from '@/ui/label/label.component'
  import { UiSectionCardComponent } from '@/ui/section-card/section-card.component'
  import {
    UiSelectComponent,
    UiSelectContentComponent,
    UiSelectItemComponent,
    UiSelectTriggerComponent,
    UiSelectValueComponent,
  } from '@/ui/select/select.component'
  import { UiSeparatorComponent } from '@/ui/separator/separator.component'
  import { UiStepperComponent, type StepperStep } from '@/ui/stepper/stepper.component'
  import { UiTextareaComponent } from '@/ui/textarea/textarea.component'
  
  export interface PatientIntakeData {
    firstName: string
    middleName: string
    lastName: string
    preferredName: string
    dob: string
    biologicalSex: string
    maritalStatus: string
    phone: string
    email: string
    streetAddress: string
    city: string
    state: string
    zipCode: string
    emergencyName: string
    emergencyRelationship: string
    emergencyPhone: string
    chronicConditions: string[]
    hasAllergies: boolean
    allergyDetails: string
    currentMedications: string
    pastSurgeries: string
    primaryCarePhysician: string
    clinicPhone: string
    insuranceCarrier: string
    memberId: string
    groupNumber: string
    policyholderName: string
    policyholderRelationship: string
    frontCardUploaded: boolean
    backCardUploaded: boolean
    hipaaConsent: boolean
    treatmentConsent: boolean
    telehealthConsent: boolean
    signatureName: string
    signatureDate: string
    signerRole: string
  }
  
  const steps: StepperStep[] = [
    { id: 1, title: 'Personal Information', description: 'Demographics & Contact' },
    { id: 2, title: 'Medical History', description: 'Conditions & Medications' },
    { id: 3, title: 'Insurance & Billing', description: 'Coverage & Card Photos' },
    { id: 4, title: 'Consent & Sign', description: 'HIPAA & Authorization' },
  ]
  
  const CHRONIC_CONDITIONS = [
    { id: 'hypertension', label: 'Hypertension (High Blood Pressure)' },
    { id: 'diabetes', label: 'Diabetes (Type 1 or Type 2)' },
    { id: 'asthma', label: 'Asthma / Respiratory Conditions' },
    { id: 'heart_disease', label: 'Coronary Artery / Heart Disease' },
    { id: 'arthritis', label: 'Arthritis / Chronic Joint Pain' },
    { id: 'cancer', label: 'Cancer / Remission History' },
    { id: 'thyroid', label: 'Thyroid / Endocrine Disorder' },
    { id: 'anxiety_depression', label: 'Depression / Clinical Anxiety' },
    { id: 'kidney_disease', label: 'Chronic Kidney Disease' },
    { id: 'gerd', label: 'Acid Reflux / GERD' },
  ]
  
  const INSURANCE_CARRIERS = [
    { id: 'bcbs', label: 'BlueCross BlueShield' },
    { id: 'aetna', label: 'Aetna Health' },
    { id: 'cigna', label: 'Cigna Healthcare' },
    { id: 'united', label: 'UnitedHealthcare' },
    { id: 'medicare', label: 'Medicare Part A / B' },
    { id: 'medicaid', label: 'Medicaid' },
    { id: 'humana', label: 'Humana' },
    { id: 'kaiser', label: 'Kaiser Permanente' },
    { id: 'self_pay', label: 'Self-Pay (Uninsured)' },
  ]
  
  const DEFAULT_FORM: PatientIntakeData = {
    firstName: 'Eleanor',
    middleName: 'Rose',
    lastName: 'Vance',
    preferredName: 'Ellie',
    dob: '1988-10-14',
    biologicalSex: 'female',
    maritalStatus: 'married',
    phone: '(555) 234-8921',
    email: '[email protected]',
    streetAddress: '742 Evergreen Terrace',
    city: 'Springfield',
    state: 'OR',
    zipCode: '97477',
    emergencyName: 'Marcus Vance',
    emergencyRelationship: 'spouse',
    emergencyPhone: '(555) 987-6543',
    chronicConditions: ['hypertension', 'asthma'],
    hasAllergies: true,
    allergyDetails: 'Penicillin (Anaphylaxis/hives), Sulfa antibiotics (severe skin rash)',
    currentMedications:
      'Lisinopril 10mg PO once daily in morning, Albuterol HFA 90mcg inhaler 1-2 puffs Q4H PRN for bronchospasm, Multivitamin daily',
    pastSurgeries: 'Appendectomy (Laparoscopic, 2016), Right knee arthroscopy / meniscus debridement (2021)',
    primaryCarePhysician: 'Dr. Robert Chen, MD',
    clinicPhone: '(555) 601-2290 — Northwest Health Partners',
    insuranceCarrier: 'bcbs',
    memberId: 'XEH-902814891',
    groupNumber: 'GRP-44028',
    policyholderName: 'Eleanor Vance',
    policyholderRelationship: 'self',
    frontCardUploaded: true,
    backCardUploaded: true,
    hipaaConsent: true,
    treatmentConsent: true,
    telehealthConsent: true,
    signatureName: 'Eleanor R. Vance',
    signatureDate: '2026-08-21',
    signerRole: 'patient',
  }
  
  @Component({
    changeDetection: ChangeDetectionStrategy.Eager,
    selector: 'ui-patient-intake-form, [ui-patient-intake-form]',
    standalone: true,
    // React renders the SectionCard itself: the host stays out of layout and `class` goes to the card.
    host: { '[attr.class]': '"contents"' },
    imports: [
      LucideAngularModule,
      UiBadgeComponent,
      UiButtonComponent,
      UiCheckboxComponent,
      UiInputComponent,
      UiLabelComponent,
      UiSectionCardComponent,
      UiSelectComponent,
      UiSelectContentComponent,
      UiSelectItemComponent,
      UiSelectTriggerComponent,
      UiSelectValueComponent,
      UiSeparatorComponent,
      UiStepperComponent,
      UiTextareaComponent,
    ],
    template: `
      <ui-section-card
        data-slot="patient-intake-form"
        title="New Patient Registration"
        description="HIPAA-compliant digital intake questionnaire & clinical onboarding portal."
        [class]="cardClass"
      >
        <div slot="header-action" class="flex items-center gap-2">
          <span
            ui-badge
            wrap
            variant="outline"
            class="border-success/30 bg-success/10 text-success gap-1 py-0.5 text-xs font-medium"
          >
            <lucide-icon [img]="ShieldCheck" class="size-3.5" />
            HIPAA Protected
          </span>
          <span ui-badge wrap variant="secondary" class="hidden font-mono text-xs sm:inline-flex">
            Form #PHI-2026-894
          </span>
        </div>
  
        @if (step() <= 4) {
          <ui-stepper [steps]="steps" [value]="step()" (valueChange)="onStepperInput($event)" class="mb-6" />
        }
  
        <!-- STEP 1: Personal Information -->
        @if (step() === 1) {
          <div class="space-y-6">
            <div class="border-border/80 bg-muted/40 flex items-start gap-3 rounded-lg border p-3.5 text-xs">
              <lucide-icon [img]="ShieldCheck" class="text-primary mt-0.5 size-4 shrink-0" />
              <div class="space-y-0.5">
                <p class="text-foreground font-semibold">Protected Health Information (PHI) Notice</p>
                <p class="text-muted-foreground leading-relaxed">
                  All legal demographics and medical history submitted through this portal are encrypted in accordance
                  with federal HIPAA Omnibus rules and directly synchronized with the clinic's Electronic Health Record
                  (EHR).
                </p>
              </div>
            </div>
  
            <div class="space-y-3">
              <h3 class="text-foreground flex items-center gap-2 text-xs font-semibold">
                <lucide-icon [img]="User" class="text-primary size-3.5" />
                Legal Patient Identification
              </h3>
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-2 lg:grid-cols-4">
                <div class="space-y-1.5 sm:col-span-1">
                  <label ui-label for="pi-first-name" class="text-xs">Legal First Name *</label>
                  <ui-input
                    id="pi-first-name"
                    [value]="form().firstName"
                    (valueChange)="setField('firstName', $event)"
                    placeholder="First name"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5 sm:col-span-1">
                  <label ui-label for="pi-middle-name" class="text-xs">Middle Name</label>
                  <ui-input
                    id="pi-middle-name"
                    [value]="form().middleName"
                    (valueChange)="setField('middleName', $event)"
                    placeholder="Middle name"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5 sm:col-span-1">
                  <label ui-label for="pi-last-name" class="text-xs">Legal Last Name *</label>
                  <ui-input
                    id="pi-last-name"
                    [value]="form().lastName"
                    (valueChange)="setField('lastName', $event)"
                    placeholder="Last name"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5 sm:col-span-1">
                  <label ui-label for="pi-preferred-name" class="text-xs">Preferred Name</label>
                  <ui-input
                    id="pi-preferred-name"
                    [value]="form().preferredName"
                    (valueChange)="setField('preferredName', $event)"
                    placeholder="Nickname / Preferred"
                    size="small"
                  />
                </div>
              </div>
            </div>
  
            <ui-separator />
  
            <div class="space-y-3">
              <h3 class="text-foreground flex items-center gap-2 text-xs font-semibold">
                <lucide-icon [img]="Calendar" class="text-primary size-3.5" />
                Birth & Clinical Demographics
              </h3>
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-3">
                <div class="space-y-1.5">
                  <label ui-label for="pi-dob" class="text-xs">Date of Birth *</label>
                  <ui-input
                    id="pi-dob"
                    [value]="form().dob"
                    (valueChange)="setField('dob', $event)"
                    type="date"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="pi-biological-sex" class="text-xs">Biological Sex Assigned at Birth *</label>
                  <ui-select [value]="form().biologicalSex" (valueChange)="setField('biologicalSex', $event)">
                    <button ui-select-trigger id="pi-biological-sex" size="sm" class="h-8 text-xs">
                      <ui-select-value placeholder="Select sex" />
                    </button>
                    <ui-select-content>
                      <ui-select-item value="female">Female</ui-select-item>
                      <ui-select-item value="male">Male</ui-select-item>
                      <ui-select-item value="intersex">Intersex</ui-select-item>
                      <ui-select-item value="undisclosed">Prefer not to disclose</ui-select-item>
                    </ui-select-content>
                  </ui-select>
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="pi-marital-status" class="text-xs">Marital Status</label>
                  <ui-select [value]="form().maritalStatus" (valueChange)="setField('maritalStatus', $event)">
                    <button ui-select-trigger id="pi-marital-status" size="sm" class="h-8 text-xs">
                      <ui-select-value placeholder="Select status" />
                    </button>
                    <ui-select-content>
                      <ui-select-item value="single">Single</ui-select-item>
                      <ui-select-item value="married">Married</ui-select-item>
                      <ui-select-item value="divorced">Divorced</ui-select-item>
                      <ui-select-item value="widowed">Widowed</ui-select-item>
                      <ui-select-item value="other">Other</ui-select-item>
                    </ui-select-content>
                  </ui-select>
                </div>
              </div>
            </div>
  
            <ui-separator />
  
            <div class="space-y-3">
              <h3 class="text-foreground flex items-center gap-2 text-xs font-semibold">
                <lucide-icon [img]="Phone" class="text-primary size-3.5" />
                Contact & Residential Address
              </h3>
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-2">
                <div class="space-y-1.5">
                  <label ui-label for="pi-phone" class="text-xs">Mobile Phone Number *</label>
                  <ui-input
                    id="pi-phone"
                    [value]="form().phone"
                    (valueChange)="setField('phone', $event)"
                    type="tel"
                    placeholder="(555) 234-8921"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="pi-email" class="text-xs">Email Address *</label>
                  <ui-input
                    id="pi-email"
                    [value]="form().email"
                    (valueChange)="setField('email', $event)"
                    type="email"
                    placeholder="[email protected]"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5 sm:col-span-2">
                  <label ui-label for="pi-address" class="text-xs">Street Address *</label>
                  <ui-input
                    id="pi-address"
                    [value]="form().streetAddress"
                    (valueChange)="setField('streetAddress', $event)"
                    placeholder="Street, Apt / Suite"
                    size="small"
                  />
                </div>
                <div class="grid grid-cols-1 gap-3 sm:col-span-2 sm:grid-cols-3">
                  <div class="col-span-1 space-y-1.5">
                    <label ui-label for="pi-city" class="text-xs">City</label>
                    <ui-input
                      id="pi-city"
                      [value]="form().city"
                      (valueChange)="setField('city', $event)"
                      placeholder="City"
                      size="small"
                    />
                  </div>
                  <div class="col-span-1 space-y-1.5">
                    <label ui-label for="pi-state" class="text-xs">State</label>
                    <ui-input
                      id="pi-state"
                      [value]="form().state"
                      (valueChange)="setField('state', $event)"
                      placeholder="State / Province"
                      size="small"
                    />
                  </div>
                  <div class="col-span-1 space-y-1.5">
                    <label ui-label for="pi-zip" class="text-xs">ZIP Code</label>
                    <ui-input
                      id="pi-zip"
                      [value]="form().zipCode"
                      (valueChange)="setField('zipCode', $event)"
                      placeholder="ZIP code"
                      size="small"
                    />
                  </div>
                </div>
              </div>
            </div>
  
            <ui-separator />
  
            <div class="border-border bg-muted/20 space-y-3 rounded-lg border p-4">
              <div class="flex flex-wrap items-center justify-between">
                <div class="flex items-center gap-2">
                  <lucide-icon [img]="UserCheck" class="text-primary size-4" />
                  <h4 class="text-foreground text-xs font-semibold">
                    Emergency Contact (Designated Healthcare Surrogate)
                  </h4>
                </div>
                <span ui-badge wrap variant="secondary" class="text-xs">Required</span>
              </div>
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-3">
                <div class="space-y-1.5">
                  <label ui-label for="pi-emg-name" class="text-xs">Contact Full Name *</label>
                  <ui-input
                    id="pi-emg-name"
                    [value]="form().emergencyName"
                    (valueChange)="setField('emergencyName', $event)"
                    placeholder="Full legal name"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="pi-emg-rel" class="text-xs">Relationship to Patient *</label>
                  <ui-select
                    [value]="form().emergencyRelationship"
                    (valueChange)="setField('emergencyRelationship', $event)"
                  >
                    <button ui-select-trigger id="pi-emg-rel" size="sm" class="h-8 text-xs">
                      <ui-select-value placeholder="Relationship" />
                    </button>
                    <ui-select-content>
                      <ui-select-item value="spouse">Spouse</ui-select-item>
                      <ui-select-item value="parent">Parent / Guardian</ui-select-item>
                      <ui-select-item value="child">Adult Child</ui-select-item>
                      <ui-select-item value="sibling">Sibling</ui-select-item>
                      <ui-select-item value="friend">Friend / Relative</ui-select-item>
                      <ui-select-item value="other">Other Legal Representative</ui-select-item>
                    </ui-select-content>
                  </ui-select>
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="pi-emg-phone" class="text-xs">Emergency Phone *</label>
                  <ui-input
                    id="pi-emg-phone"
                    [value]="form().emergencyPhone"
                    (valueChange)="setField('emergencyPhone', $event)"
                    type="tel"
                    placeholder="(555) 987-6543"
                    size="small"
                  />
                </div>
              </div>
            </div>
          </div>
        }
  
        <!-- STEP 2: Medical History -->
        @if (step() === 2) {
          <div class="space-y-6">
            <div class="space-y-3">
              <div class="flex flex-wrap items-center justify-between">
                <div class="flex items-center gap-2">
                  <lucide-icon [img]="Activity" class="text-primary size-4" />
                  <h3 class="text-foreground text-xs font-semibold">Chronic & Pre-Existing Health Conditions</h3>
                </div>
                <span ui-badge wrap variant="secondary" class="font-mono text-xs tabular-nums">
                  {{ form().chronicConditions.length }} selected
                </span>
              </div>
              <p class="text-muted-foreground text-xs">
                Select any conditions diagnosed or treated in the past 5 years. If none apply, leave unchecked.
              </p>
              <div class="grid grid-cols-1 gap-2.5 sm:grid-cols-2">
                @for (cond of chronicConditions; track cond.id) {
                  <div
                    class="border-border hover:bg-muted/30 flex items-center gap-2.5 rounded-lg border p-2.5 transition-colors"
                  >
                    <ui-checkbox
                      [id]="'condition-' + cond.id"
                      [checked]="form().chronicConditions.includes(cond.id)"
                      (checkedChange)="toggleCondition(cond.id, $event)"
                    />
                    <label
                      ui-label
                      [for]="'condition-' + cond.id"
                      class="flex-1 cursor-pointer text-xs font-normal select-none"
                    >
                      {{ cond.label }}
                    </label>
                  </div>
                }
              </div>
            </div>
  
            <ui-separator />
  
            <div class="border-border bg-muted/20 space-y-3 rounded-lg border p-4">
              <div class="flex flex-wrap items-center justify-between">
                <div class="flex items-center gap-2">
                  <lucide-icon [img]="AlertTriangle" class="text-warning size-4" />
                  <h4 class="text-foreground text-xs font-semibold">Known Drug, Latex, or Food Allergies</h4>
                </div>
                <div class="flex items-center gap-2">
                  <ui-checkbox
                    id="mh-has-allergies"
                    [checked]="form().hasAllergies"
                    (checkedChange)="setField('hasAllergies', !!$event)"
                    label="I have known allergies"
                  />
                </div>
              </div>
              @if (form().hasAllergies) {
                <div class="space-y-1.5 pt-1">
                  <label ui-label for="mh-allergy-details" class="text-xs">
                    List Specific Allergens & Adverse Reactions *
                  </label>
                  <ui-input
                    id="mh-allergy-details"
                    [value]="form().allergyDetails"
                    (valueChange)="setField('allergyDetails', $event)"
                    placeholder="e.g., Penicillin (Anaphylaxis), Sulfa (Severe Rash), Peanuts (Hives), Latex"
                    size="small"
                  />
                </div>
              } @else {
                <p class="text-muted-foreground text-xs italic">No known drug, latex, or food allergies reported.</p>
              }
            </div>
  
            <ui-separator />
  
            <div class="space-y-2">
              <div class="flex items-center gap-2">
                <lucide-icon [img]="Stethoscope" class="text-primary size-4" />
                <label ui-label for="mh-medications" class="text-xs font-semibold">
                  Current Prescription & OTC Medications
                </label>
              </div>
              <ui-textarea
                id="mh-medications"
                [value]="form().currentMedications"
                (valueChange)="setField('currentMedications', $event)"
                [rows]="3"
                placeholder="Include drug name, dosage, and schedule (e.g., Lisinopril 10mg once daily in AM, Metformin 500mg BID with meals)..."
                class="text-xs"
              />
              <p class="text-muted-foreground text-xs">
                Include all daily vitamins, herbal supplements, inhalers, and injections.
              </p>
            </div>
  
            <ui-separator />
  
            <div class="space-y-2">
              <div class="flex items-center gap-2">
                <lucide-icon [img]="FileText" class="text-primary size-4" />
                <label ui-label for="mh-surgeries" class="text-xs font-semibold">
                  Past Surgeries, Major Injuries & Hospitalizations
                </label>
              </div>
              <ui-textarea
                id="mh-surgeries"
                [value]="form().pastSurgeries"
                (valueChange)="setField('pastSurgeries', $event)"
                [rows]="2"
                placeholder="List approximate year and procedure (e.g., Appendectomy 2016, Knee Arthroscopy 2021)..."
                class="text-xs"
              />
            </div>
  
            <ui-separator />
  
            <div class="space-y-3">
              <h4 class="text-foreground text-xs font-semibold">Primary Care Provider / Referring Clinic</h4>
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-2">
                <div class="space-y-1.5">
                  <label ui-label for="mh-pcp-name" class="text-xs">Physician or Practice Name</label>
                  <ui-input
                    id="mh-pcp-name"
                    [value]="form().primaryCarePhysician"
                    (valueChange)="setField('primaryCarePhysician', $event)"
                    placeholder="Dr. Robert Chen, MD"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="mh-clinic-phone" class="text-xs">Clinic Contact / Phone</label>
                  <ui-input
                    id="mh-clinic-phone"
                    [value]="form().clinicPhone"
                    (valueChange)="setField('clinicPhone', $event)"
                    placeholder="(555) 601-2290"
                    size="small"
                  />
                </div>
              </div>
            </div>
          </div>
        }
  
        <!-- STEP 3: Insurance & Billing -->
        @if (step() === 3) {
          <div class="space-y-6">
            <div class="space-y-3">
              <div class="flex flex-wrap items-center justify-between">
                <div class="flex items-center gap-2">
                  <lucide-icon [img]="Building2" class="text-primary size-4" />
                  <h3 class="text-foreground text-xs font-semibold">Primary Medical Insurance Carrier</h3>
                </div>
                <span ui-badge wrap variant="outline" class="text-xs">Primary Plan</span>
              </div>
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-3">
                <div class="space-y-1.5">
                  <label ui-label for="ins-carrier" class="text-xs">Insurance Carrier *</label>
                  <ui-select [value]="form().insuranceCarrier" (valueChange)="setField('insuranceCarrier', $event)">
                    <button ui-select-trigger id="ins-carrier" size="sm" class="h-8 text-xs">
                      <ui-select-value placeholder="Select carrier" />
                    </button>
                    <ui-select-content>
                      @for (carrier of insuranceCarriers; track carrier.id) {
                        <ui-select-item [value]="carrier.id">{{ carrier.label }}</ui-select-item>
                      }
                    </ui-select-content>
                  </ui-select>
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="ins-member-id" class="text-xs">Member / Subscriber ID *</label>
                  <ui-input
                    id="ins-member-id"
                    [value]="form().memberId"
                    (valueChange)="setField('memberId', $event)"
                    placeholder="e.g. XEH-902814891"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="ins-group-num" class="text-xs">Group Number</label>
                  <ui-input
                    id="ins-group-num"
                    [value]="form().groupNumber"
                    (valueChange)="setField('groupNumber', $event)"
                    placeholder="e.g. GRP-44028"
                    size="small"
                  />
                </div>
              </div>
            </div>
  
            <ui-separator />
  
            <div class="space-y-3">
              <h3 class="text-foreground flex items-center gap-2 text-xs font-semibold">
                <lucide-icon [img]="User" class="text-primary size-3.5" />
                Primary Policyholder Information
              </h3>
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-2">
                <div class="space-y-1.5">
                  <label ui-label for="ins-holder-name" class="text-xs">Primary Insured Full Legal Name *</label>
                  <ui-input
                    id="ins-holder-name"
                    [value]="form().policyholderName"
                    (valueChange)="setField('policyholderName', $event)"
                    placeholder="Policyholder name"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5">
                  <label ui-label for="ins-holder-rel" class="text-xs">Relationship to Patient *</label>
                  <ui-select
                    [value]="form().policyholderRelationship"
                    (valueChange)="setField('policyholderRelationship', $event)"
                  >
                    <button ui-select-trigger id="ins-holder-rel" size="sm" class="h-8 text-xs">
                      <ui-select-value placeholder="Relationship" />
                    </button>
                    <ui-select-content>
                      <ui-select-item value="self">Self (Patient is Policyholder)</ui-select-item>
                      <ui-select-item value="spouse">Spouse</ui-select-item>
                      <ui-select-item value="child">Child / Dependent</ui-select-item>
                      <ui-select-item value="other">Other Legal Custodian</ui-select-item>
                    </ui-select-content>
                  </ui-select>
                </div>
              </div>
            </div>
  
            <ui-separator />
  
            <div class="space-y-3">
              <div class="flex flex-wrap items-center justify-between">
                <div class="flex items-center gap-2">
                  <lucide-icon [img]="CreditCard" class="text-primary size-4" />
                  <h3 class="text-foreground text-xs font-semibold">Insurance Card Photo Verification</h3>
                </div>
                <span class="text-muted-foreground text-xs">PNG, JPG, PDF up to 10MB</span>
              </div>
              <p class="text-muted-foreground text-xs">
                Provide high-resolution photos of both front and back sides of your insurance card for optical character
                recognition (OCR) and benefit eligibility verification.
              </p>
  
              <div class="grid grid-cols-1 gap-4 sm:grid-cols-2">
                <div
                  class="border-border bg-card hover:bg-muted/20 flex flex-col justify-between rounded-xl border p-4 text-center transition-colors"
                >
                  <div class="space-y-2 py-3">
                    <div class="bg-primary/10 text-primary mx-auto flex size-10 items-center justify-center rounded-full">
                      <lucide-icon [img]="CreditCard" class="size-5" />
                    </div>
                    <div class="space-y-0.5">
                      <p class="text-foreground text-xs font-semibold">Front of Insurance Card</p>
                      <p class="text-muted-foreground text-xs">Subscriber ID & carrier logo visible</p>
                    </div>
                  </div>
                  <div
                    class="border-border/60 bg-muted/40 flex flex-wrap items-center justify-between rounded-md border px-3 py-2 text-xs"
                  >
                    @if (form().frontCardUploaded) {
                      <span class="text-success flex items-center gap-1.5 font-medium">
                        <lucide-icon [img]="Check" class="size-3.5" />
                        card_front_scan.jpg (2.4 MB)
                      </span>
                    } @else {
                      <span class="text-muted-foreground">No file selected</span>
                    }
                    <button
                      ui-button
                      type="button"
                      variant="outline"
                      size="sm"
                      class="h-7 text-xs font-medium"
                      (click)="toggleUpload('frontCardUploaded')"
                    >
                      {{ form().frontCardUploaded ? 'Replace' : 'Upload Front' }}
                    </button>
                  </div>
                </div>
  
                <div
                  class="border-border bg-card hover:bg-muted/20 flex flex-col justify-between rounded-xl border p-4 text-center transition-colors"
                >
                  <div class="space-y-2 py-3">
                    <div class="bg-primary/10 text-primary mx-auto flex size-10 items-center justify-center rounded-full">
                      <lucide-icon [img]="CreditCard" class="size-5" />
                    </div>
                    <div class="space-y-0.5">
                      <p class="text-foreground text-xs font-semibold">Back of Insurance Card</p>
                      <p class="text-muted-foreground text-xs">Claims address & Rx BIN visible</p>
                    </div>
                  </div>
                  <div
                    class="border-border/60 bg-muted/40 flex flex-wrap items-center justify-between rounded-md border px-3 py-2 text-xs"
                  >
                    @if (form().backCardUploaded) {
                      <span class="text-success flex items-center gap-1.5 font-medium">
                        <lucide-icon [img]="Check" class="size-3.5" />
                        card_back_scan.jpg (1.9 MB)
                      </span>
                    } @else {
                      <span class="text-muted-foreground">No file selected</span>
                    }
                    <button
                      ui-button
                      type="button"
                      variant="outline"
                      size="sm"
                      class="h-7 text-xs font-medium"
                      (click)="toggleUpload('backCardUploaded')"
                    >
                      {{ form().backCardUploaded ? 'Replace' : 'Upload Back' }}
                    </button>
                  </div>
                </div>
              </div>
            </div>
          </div>
        }
  
        <!-- STEP 4: Consent & Sign -->
        @if (step() === 4) {
          <div class="space-y-6">
            <div class="space-y-2">
              <div class="flex flex-wrap items-center justify-between">
                <div class="flex items-center gap-2">
                  <lucide-icon [img]="FileText" class="text-primary size-4" />
                  <h3 class="text-foreground text-xs font-semibold">Regulatory Disclosures & Legal Notice</h3>
                </div>
                <span ui-badge wrap variant="secondary" class="text-xs">Mandatory Acknowledgement</span>
              </div>
              <div
                class="border-border bg-muted/20 text-muted-foreground max-h-40 space-y-3 overflow-y-auto rounded-lg border p-3.5 text-xs leading-relaxed"
              >
                <div>
                  <span class="text-foreground font-semibold">1. HIPAA Notice of Privacy Practices:</span>
                  I acknowledge receipt and review of the Notice of Privacy Practices, which describes how my Protected
                  Health Information (PHI) may be used and disclosed for clinical treatment, payment processing, and
                  healthcare operations in strict compliance with the HIPAA Omnibus Rule (45 CFR § 164.520).
                </div>
                <div>
                  <span class="text-foreground font-semibold">2. Informed Consent for Outpatient Treatment:</span>
                  I voluntarily authorize the clinical physicians and allied healthcare team to perform diagnostic
                  evaluations, blood tests, physical examinations, and outpatient clinical care deemed medically
                  necessary.
                </div>
                <div>
                  <span class="text-foreground font-semibold">3. Assignment of Benefits & Financial Agreement:</span>
                  I assign all medical insurance benefits directly to the provider. I acknowledge that I remain
                  financially responsible for copayments, deductibles, and non-covered services not adjudicated by my
                  carrier.
                </div>
              </div>
            </div>
  
            <div class="divide-border divide-y rounded-lg border">
              <div class="flex items-start gap-3 p-3.5">
                <ui-checkbox
                  id="cs-hipaa-consent"
                  [checked]="form().hipaaConsent"
                  (checkedChange)="setField('hipaaConsent', !!$event)"
                  class="mt-0.5"
                />
                <div class="space-y-0.5">
                  <label ui-label for="cs-hipaa-consent" class="cursor-pointer text-xs font-medium">
                    HIPAA Privacy Practices Acknowledgement *
                  </label>
                  <p class="text-muted-foreground text-xs">
                    I have read, understood, and accept the HIPAA Notice of Privacy Practices and consent to electronic
                    medical record management.
                  </p>
                </div>
              </div>
  
              <div class="flex items-start gap-3 p-3.5">
                <ui-checkbox
                  id="cs-treatment-consent"
                  [checked]="form().treatmentConsent"
                  (checkedChange)="setField('treatmentConsent', !!$event)"
                  class="mt-0.5"
                />
                <div class="space-y-0.5">
                  <label ui-label for="cs-treatment-consent" class="cursor-pointer text-xs font-medium">
                    Informed Treatment Consent & Benefit Assignment *
                  </label>
                  <p class="text-muted-foreground text-xs">
                    I authorize medical evaluation and agree to the assignment of insurance benefits to the clinical care
                    provider.
                  </p>
                </div>
              </div>
  
              <div class="flex items-start gap-3 p-3.5">
                <ui-checkbox
                  id="cs-telehealth-consent"
                  [checked]="form().telehealthConsent"
                  (checkedChange)="setField('telehealthConsent', !!$event)"
                  class="mt-0.5"
                />
                <div class="space-y-0.5">
                  <label ui-label for="cs-telehealth-consent" class="cursor-pointer text-xs font-medium">
                    Telehealth & Encrypted Digital Communications (Optional)
                  </label>
                  <p class="text-muted-foreground text-xs">
                    I consent to virtual video consultations and automated SMS/email appointment notifications and lab
                    report alerts.
                  </p>
                </div>
              </div>
            </div>
  
            <ui-separator />
  
            <div class="space-y-4">
              <div class="flex flex-wrap items-center justify-between">
                <div class="flex items-center gap-2">
                  <lucide-icon [img]="Lock" class="text-primary size-4" />
                  <h3 class="text-foreground text-xs font-semibold">Electronic Signature & Digital Certification</h3>
                </div>
                <span ui-badge wrap variant="outline" class="border-primary/30 text-primary font-mono text-xs">
                  256-bit Certified
                </span>
              </div>
  
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-3">
                <div class="space-y-1.5 sm:col-span-1">
                  <label ui-label for="cs-signer-name" class="text-xs">Type Full Legal Name as Signature *</label>
                  <ui-input
                    id="cs-signer-name"
                    [value]="form().signatureName"
                    (valueChange)="setField('signatureName', $event)"
                    placeholder="e.g. Eleanor R. Vance"
                    size="small"
                  />
                </div>
                <div class="space-y-1.5 sm:col-span-1">
                  <label ui-label for="cs-signer-role" class="text-xs">Signer Capacity / Role *</label>
                  <ui-select [value]="form().signerRole" (valueChange)="setField('signerRole', $event)">
                    <button ui-select-trigger id="cs-signer-role" size="sm" class="h-8 text-xs">
                      <ui-select-value placeholder="Select role" />
                    </button>
                    <ui-select-content>
                      <ui-select-item value="patient">Patient (Self)</ui-select-item>
                      <ui-select-item value="parent_guardian">Parent / Legal Guardian</ui-select-item>
                      <ui-select-item value="poa">Medical Power of Attorney</ui-select-item>
                    </ui-select-content>
                  </ui-select>
                </div>
                <div class="space-y-1.5 sm:col-span-1">
                  <label ui-label for="cs-sig-date" class="text-xs">Signature Date *</label>
                  <ui-input
                    id="cs-sig-date"
                    [value]="form().signatureDate"
                    (valueChange)="setField('signatureDate', $event)"
                    type="date"
                    size="small"
                  />
                </div>
              </div>
  
              <div class="border-primary/30 bg-primary/5 space-y-3 rounded-xl border p-4">
                <div class="flex flex-wrap items-center justify-between">
                  <span class="text-muted-foreground text-xs font-medium"> Legal Digital Signature Stamp </span>
                  <span class="text-primary flex items-center gap-1 font-mono text-xs">
                    <lucide-icon [img]="ShieldCheck" class="size-3.5" />
                    Verified & Timestamped
                  </span>
                </div>
  
                <div class="border-primary/20 border-b pt-1 pb-3">
                  <p class="text-primary text-2xl font-medium tracking-wide italic">
                    {{ form().signatureName || 'Your Signature' }}
                  </p>
                </div>
  
                <div class="text-muted-foreground flex flex-wrap items-center justify-between gap-2 font-mono text-xs">
                  <span>Signer: {{ form().signatureName || 'Eleanor Vance' }} ({{ form().signerRole }})</span>
                  <span>Date: {{ form().signatureDate }} · Ref #SIG-49102-HIPAA</span>
                </div>
              </div>
            </div>
          </div>
        }
  
        <!-- STEP 5: Success / Confirmation Receipt -->
        @if (step() === 5) {
          <div class="space-y-6 py-4 text-center">
            <div
              class="border-success/30 bg-success/10 text-success mx-auto flex size-16 items-center justify-center rounded-full border shadow-xs"
            >
              <lucide-icon [img]="Check" class="size-8" />
            </div>
  
            <div class="space-y-1">
              <h3 class="text-foreground text-xl font-bold tracking-tight">Patient Intake Submitted Successfully</h3>
              <p class="text-muted-foreground mx-auto max-w-md text-xs sm:text-sm">
                Your new patient registration and encrypted medical disclosures have been received and queued for clinical
                triage.
              </p>
            </div>
  
            <div class="border-border inline-flex items-center gap-2 rounded-full border px-3 py-1 text-xs">
              <span class="text-muted-foreground">Confirmation ID:</span>
              <span class="text-foreground font-mono font-bold">{{ intakeId() }}</span>
            </div>
  
            <div class="border-border bg-muted/30 mx-auto max-w-xl space-y-3 rounded-xl border p-4 text-left text-xs">
              <div class="grid grid-cols-1 gap-3 sm:grid-cols-2">
                <div>
                  <span class="text-muted-foreground block">Patient Name:</span>
                  <span class="text-foreground font-semibold"
                    >{{ form().firstName }} {{ form().middleName }} {{ form().lastName }}</span
                  >
                </div>
                <div>
                  <span class="text-muted-foreground block">Date of Birth:</span>
                  <span class="text-foreground font-medium tabular-nums"
                    >{{ form().dob }} ({{ form().biologicalSex }})</span
                  >
                </div>
                <div>
                  <span class="text-muted-foreground block">Primary Insurance:</span>
                  <span class="text-foreground font-medium"
                    >{{ selectedCarrierLabel() }} (ID: {{ form().memberId }})</span
                  >
                </div>
                <div>
                  <span class="text-muted-foreground block">Emergency Contact:</span>
                  <span class="text-foreground font-medium"
                    >{{ form().emergencyName }} ({{ form().emergencyPhone }})</span
                  >
                </div>
                <div
                  class="border-border/60 col-span-1 flex flex-wrap items-center justify-between border-t pt-2 sm:col-span-2"
                >
                  <span class="text-muted-foreground">Legal Signature:</span>
                  <span class="text-primary font-medium tracking-wide italic"
                    >{{ form().signatureName }} ({{ form().signatureDate }})</span
                  >
                </div>
              </div>
            </div>
  
            <div class="flex flex-wrap items-center justify-center gap-3 pt-2">
              <button
                ui-button
                aria-label="Download attachment"
                variant="outline"
                size="sm"
                class="gap-1.5 text-xs font-medium"
              >
                <lucide-icon [img]="Download" class="size-3.5" />
                Download Intake PDF
              </button>
              <button ui-button size="sm" class="gap-1.5 text-xs font-medium" (click)="resetForm()">
                <lucide-icon [img]="RotateCcw" class="size-3.5" />
                Register Another Patient
              </button>
            </div>
          </div>
        }
  
        <div slot="footer" class="border-border bg-muted/20 flex w-full items-center justify-between border-t px-6 py-4">
          @if (step() > 1 && step() <= 4) {
            <button ui-button variant="ghost" size="sm" class="gap-1.5 text-xs font-medium" (click)="goBack()">
              <lucide-icon [img]="ChevronLeft" class="size-4" />
              Back
            </button>
          } @else {
            <span aria-hidden="true"></span>
          }
  
          @if (step() <= 4) {
            <span class="text-muted-foreground text-xs font-medium"> Step {{ step() }} of 4 — {{ stepTitle() }} </span>
          } @else {
            <span class="text-muted-foreground text-xs font-medium">Registration Complete</span>
          }
  
          @if (step() < 4) {
            <button
              ui-button
              size="sm"
              class="gap-1.5 text-xs font-medium"
              [disabled]="continueDisabled()"
              (click)="goNext()"
            >
              Continue
              <lucide-icon [img]="ChevronRight" class="size-4" />
            </button>
          } @else if (step() === 4) {
            <button
              ui-button
              size="sm"
              class="bg-primary text-primary-foreground gap-1.5 text-xs font-medium"
              [disabled]="submitDisabled()"
              (click)="handleSubmit()"
            >
              <lucide-icon [img]="FileCheck" class="size-4" />
              Submit Registration
            </button>
          } @else {
            <span aria-hidden="true"></span>
          }
        </div>
      </ui-section-card>
    `,
  })
  export class UiPatientIntakeFormComponent {
    protected readonly Activity = Activity
    protected readonly AlertTriangle = AlertTriangle
    protected readonly Building2 = Building2
    protected readonly Calendar = Calendar
    protected readonly Check = Check
    protected readonly ChevronLeft = ChevronLeft
    protected readonly ChevronRight = ChevronRight
    protected readonly CreditCard = CreditCard
    protected readonly Download = Download
    protected readonly FileCheck = FileCheck
    protected readonly FileText = FileText
    protected readonly Lock = Lock
    protected readonly Phone = Phone
    protected readonly RotateCcw = RotateCcw
    protected readonly ShieldCheck = ShieldCheck
    protected readonly Stethoscope = Stethoscope
    protected readonly User = User
    protected readonly UserCheck = UserCheck
  
    protected readonly steps = steps
    protected readonly chronicConditions = CHRONIC_CONDITIONS
    protected readonly insuranceCarriers = INSURANCE_CARRIERS
  
    @Input('class') className?: string
  
    readonly step = signal(1)
    readonly submitted = signal(false)
    readonly intakeId = signal('INTAKE-2026-8942')
    readonly form = signal<PatientIntakeData>({
      ...DEFAULT_FORM,
      chronicConditions: [...DEFAULT_FORM.chronicConditions],
    })
  
    @Input('initialStep') set initialStepAttr(v: number | undefined) {
      if (v !== undefined) this.step.set(v)
    }
    @Input('initialData') set initialDataAttr(v: Partial<PatientIntakeData> | undefined) {
      if (v !== undefined) {
        this.form.update((prev) => ({
          ...prev,
          ...v,
          chronicConditions: v.chronicConditions ? [...v.chronicConditions] : [...prev.chronicConditions],
        }))
      }
    }
  
    @Output() readonly submit = new EventEmitter<PatientIntakeData>()
    @Output() readonly stepChange = new EventEmitter<number>()
  
    readonly selectedCarrierLabel = computed(() => {
      const found = INSURANCE_CARRIERS.find((c) => c.id === this.form().insuranceCarrier)
      return found ? found.label : this.form().insuranceCarrier
    })
  
    readonly stepTitle = computed(() => steps[this.step() - 1]?.title ?? '')
  
    readonly continueDisabled = computed(
      () => this.step() === 1 && (this.form().firstName.trim() === '' || this.form().lastName.trim() === ''),
    )
  
    readonly submitDisabled = computed(
      () => !this.form().hipaaConsent || !this.form().treatmentConsent || this.form().signatureName.trim() === '',
    )
  
    get cardClass(): string {
      return cn('max-w-4xl', this.className)
    }
  
    setField<K extends keyof PatientIntakeData>(key: K, value: PatientIntakeData[K]): void {
      this.form.update((prev) => ({ ...prev, [key]: value }))
    }
  
    toggleCondition(conditionId: string, checked: boolean | 'indeterminate'): void {
      this.form.update((prev) => {
        if (checked === true) {
          if (prev.chronicConditions.includes(conditionId)) return prev
          return { ...prev, chronicConditions: [...prev.chronicConditions, conditionId] }
        }
        return { ...prev, chronicConditions: prev.chronicConditions.filter((id) => id !== conditionId) }
      })
    }
  
    toggleUpload(key: 'frontCardUploaded' | 'backCardUploaded'): void {
      this.form.update((prev) => ({ ...prev, [key]: !prev[key] }))
    }
  
    onStepperInput(value: number): void {
      // Backward navigation through the stepper is free; forward goes through Continue.
      if (value < this.step() && this.step() !== 5) {
        this.step.set(value)
        this.stepChange.emit(value)
      }
    }
  
    goNext(): void {
      if (this.step() < 4) {
        const next = this.step() + 1
        this.step.set(next)
        this.stepChange.emit(next)
      }
    }
  
    goBack(): void {
      if (this.step() > 1 && this.step() <= 4) {
        const prev = this.step() - 1
        this.step.set(prev)
        this.stepChange.emit(prev)
      }
    }
  
    handleSubmit(): void {
      this.submitted.set(true)
      this.step.set(5)
      const form = this.form()
      this.submit.emit({ ...form, chronicConditions: [...form.chronicConditions] })
      this.stepChange.emit(5)
    }
  
    resetForm(): void {
      this.step.set(1)
      this.submitted.set(false)
      this.stepChange.emit(1)
    }
  }
  

• src/app/components/blocks/patient-intake-form/index.ts0.1 kB

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Raw manifest:https://uipkge.dev/r/angular/patient-intake-form.json