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Hospital Admission Form Template

Streamline Patient Registration with Our Hospital Admission Form

Facing delays in patient registration can be frustrating. Our Hospital Admission Form Template is specifically designed to help healthcare providers efficiently gather essential medical information and streamline the admission process. With this template, you can ensure accurate data collection, minimize paperwork errors, and enhance patient experience, all while maintaining compliance with healthcare regulations such as WCAG for accessibility. Start using the live template to simplify your admissions today.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Primary phone number
Email address
Home address (street, city, state/province, postal code, country)
Preferred language
English
Spanish
Prefer not to say
Other
Please Specify:
Do you require an interpreter?
Yes
No
Briefly describe your reason for admission or current symptoms
Anticipated admission date
Primary care provider (name)
Reason for visit
Scheduled surgery/procedure
Emergency or urgent care
Diagnostic test
Treatment/therapy
Maternity/obstetric care
Other
Please Specify:
Emergency contact full name
Relationship to patient
Spouse/Partner
Parent/Guardian
Child
Sibling
Relative
Friend
Caregiver
Other
Please Specify:
Emergency contact phone number
Is this person authorized to receive information about your care?
Yes
No
Primary insurance provider
Policy/Member ID
Subscriber name (if not the patient)
Subscriber date of birth
Conditions you have been diagnosed with (select all that apply)
Please Specify:
Other medical conditions or details (if any)
Current medications and doses (include over-the-counter and supplements)
Allergy types (select all that apply)
No known allergies
Medications
Food
Latex
Environmental (e.g., pollen)
Adhesives
Contrast dye/iodine
Other
Please Specify:
List specific allergies and reactions
Pregnancy status (if applicable)
Yes
No
Not applicable
Tobacco use
Never
Former
Current some days
Current every day
Prefer not to say
Accessibility or accommodation needs (optional)
Alcohol use
Never
Rarely
Sometimes
Often
Prefer not to say
I authorize the hospital and treating clinicians to provide necessary medical care and treatment.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
I acknowledge that I have received or had the opportunity to review the Notice of Privacy Practices.
Yes
No
I certify that the information provided is accurate to the best of my knowledge.
Yes
No
Name of person completing this form (acts as signature)
Signature date
Relationship to patient
Self
Parent/Guardian
Spouse/Partner
Other
Please Specify:
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Paper art illustration depicting a hospital admission form for an article on FormCreatorAI

When to use this form

Use this admission form when registering new inpatients, observation stays, or ER-to-ward transfers. It helps front desk staff and clinicians capture accurate identity, contacts, insurance, medical history, and consent in one pass. Patients benefit from shorter check-in and fewer repeated questions, while your team gets clean data for wristbands, labels, and orders. For scheduled procedures, send it ahead so you can pre-verify coverage and bed needs. If you need charts from an outside clinic, request them with the Transfer of medical records form. When a referring provider requires patient consent, pair your intake with a Medical record release form. The result: faster triage, safer medication reconciliation, and smoother billing from day one.

Must Ask Hospital Admission Questions

  1. What is your full legal name, date of birth, and a government-issued ID number?

    These identifiers ensure the right chart is matched across systems and services. They reduce duplicate records and prevent mislabeling of wristbands, medications, and lab samples.

  2. What brings you in today, and when did your symptoms start?

    This clarifies urgency and guides triage and bed placement. A clear timeline helps clinicians prioritize tests and start the right orders faster.

  3. Do you have any allergies and what medications do you take, including dose and last time taken?

    Allergy and medication details prevent adverse drug events and delays. They support safe prescribing, anesthesia planning, and accurate medication reconciliation.

  4. Have you traveled recently or had infectious disease exposures in the last 30 days?

    Travel and exposure history informs isolation, testing, and PPE decisions. You can document details with the Travel declaration form to standardize screening.

  5. Who is your emergency contact and decision-maker, and may we share updates with them?

    This ensures timely communication and clear consent during care. When preparing discharge paperwork, coordinate with the Hospital patient release form to keep contacts aligned.

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