Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

New Patient Information Form Template

Streamline patient intake with our easy-to-use template

Collecting essential information from new patients shouldn't feel overwhelming. This New Patient Information Form Template is designed for healthcare providers looking to simplify the intake process and ensure accurate data collection. With this template, you'll save time on administrative tasks, enhance patient experience, and maintain organized records. Plus, it features WCAG-aligned labels for accessibility, ensuring all patients can easily complete it. Try out the live template to see how it works for you.

Use this Template (FREE) Live Preview
Full name
Date of birth
Pronouns
Primary language
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Home address (street, city, state, ZIP)
Email address
Mobile phone
Preferred contact method
Phone call
Text message
Email
No contact
Is it okay to leave detailed voicemail or text messages about your care?
Yes
No
Emergency contact full name
Emergency contact phone
Emergency contact relationship to patient
Parent/Guardian
Spouse/Partner
Sibling
Child
Relative
Friend
Caregiver
Other
Please Specify:
Do you have health insurance?
Yes
No
Insurance provider (primary)
Member ID
Group number
Policyholder full name
Policyholder date of birth
Relationship to policyholder
Self
Spouse/Partner
Parent/Guardian
Child
Other
Please Specify:
Reason for visit or primary concern
Current medical conditions (diagnoses)
Past surgeries or hospitalizations (with dates if known)
Pregnancy status
Not applicable
Yes, currently pregnant
Planning pregnancy
No
Current medications (name, dose, frequency)
Allergy details (substances and reactions)
Known allergies
None
Medications
Food
Environmental
Latex
Prefer not to say
Other
Please Specify:
Tobacco or nicotine use
Never
Former
Current some days
Current every day
Prefer not to say
Alcohol use frequency
Never
Rarely
Sometimes
Often
Always
Primary care physician or clinic
Preferred pharmacy (name and location)
I consent to receive medical care from this practice.
Yes
No
I acknowledge receipt of the Notice of Privacy Practices (HIPAA).
Yes
No
I authorize the release of information necessary to process insurance claims and payment.
Yes
No
I accept financial responsibility for charges not covered by insurance.
Yes
No
Patient signature (type full name)
Signature date
If signing on behalf of the patient, your relationship to the patient
Self
Parent/Guardian
Spouse/Partner
Other
Please Specify:
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Date of birth, Pronouns","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration showcasing a patient information form for a healthcare article on FormCreatorAI.

When to use this form

Use this form to onboard first-time patients before a visit, so you can verify identity, contacts, insurance, and basic health details. It works for small clinics, dental offices, behavioral health, and telehealth. Collecting this upfront speeds check-in, reduces errors, and helps you prepare the chart. For deeper history, pair it with the Medical intake form, or switch to the New patient registration form when you also need consents and policy acknowledgments. Hospitals can adapt it for pre-admission screening to route patients to the right provider. The result: cleaner records, fewer phone calls, and a smoother first visit.

Must Ask New Patient Information Questions

  1. What is your full legal name and preferred name?

    This confirms identity for insurance and EHR matching and lets staff address you correctly. It reduces billing denials and builds trust from the first visit.

  2. What is your date of birth?

    Your date of birth helps match records, check eligibility, and apply age-based care guidelines. It also prevents mix-ups with patients who have similar names.

  3. What is your primary phone number, email, and preferred contact method?

    Accurate contact details let the team send reminders, instructions, and forms, and reach you quickly if plans change. Asking your preferred method and time to reach you cuts phone tag and no-shows.

  4. What is your insurance provider, member ID, and group number?

    Insurance details allow staff to verify coverage, copays, and referrals before you arrive. This avoids surprises at check-in and speeds authorization if needed.

  5. Who should we contact in an emergency (name, relationship, phone)?

    An emergency contact is vital if we cannot reach you during an urgent situation. For hospital or inpatient workflows, you can move this into a Hospital patient registration form.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel