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

Patient Admission and Consent Form Template

Streamline Your Patient Admission Process Effortlessly

Navigating the patient intake process can be challenging, but you can simplify it with our Patient Admission and Consent Form template. This template is designed for healthcare facilities looking to ensure smooth admissions and legal compliance, helping you gather essential information quickly and accurately. Benefit from reducing paperwork errors, speeding up the admission process, and enhancing patient experience, all while maintaining compliance with healthcare regulations. Explore the live template now to see how it can work for you.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Mailing address
Email address
Mobile phone
Preferred contact method
Phone call
Text/SMS
Email
No preference
Do you have health insurance?
Yes
No
Insurance provider name
Member or policy number
Primary policyholder name
Relationship to policyholder
Self
Spouse/Partner
Parent/Guardian
Child/Dependent
Other
Please Specify:
Reason for visit today
Current medications (include dose and frequency, or write None)
Allergies (medications, foods, or environmental, or write None)
Please indicate any past or current conditions that apply
Are you currently pregnant?
Yes
No
Not applicable
Prefer not to say
Tobacco or nicotine use
Never
Former
Current daily
Current occasional
Prefer not to say
Emergency contact name
Emergency contact phone
Relationship to patient
Spouse/Partner
Parent
Child
Sibling
Friend
Caregiver
Other
Please Specify:
Person completing this form
I am the patient
I am the parent/legal guardian
Other authorized representative
I consent to receive evaluation and treatment as deemed necessary by the provider
Yes
No
I consent to telehealth services, if applicable
Yes
No
Not applicable
I authorize the use and disclosure of my health information for treatment, payment, and healthcare operations as permitted by law
Yes
No
I acknowledge receipt or availability of the Notice of Privacy Practices
Yes
No
I agree to receive appointment reminders via
Phone call
Text/SMS
Email
Do not send reminders
I accept financial responsibility for charges not covered by insurance and authorize direct payment of insurance benefits to the provider
Yes
No
Signer full name (type your full legal name as signature)
Date of signature
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Gender identity","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a patient admission and consent form for healthcare documentation

When to use this form

This form is useful whenever you admit a new or returning patient for inpatient care, observation, same-day surgery, or urgent treatment. Use it at the front desk, bedside, or pre-registration to capture demographics, insurance, medical history, and consent in one pass. Many teams use it as their hospital admission form to reduce wait times and avoid missing signatures. If you expect procedures during a stay, pair it with the Consent to treat form. For unplanned events, keep an Emergency medical consent form on file to authorize necessary care if the patient cannot respond. The result: faster intake, fewer errors, and clear permissions for billing and treatment.

Must Ask Patient Admission and Consent Questions

  1. What is the reason for your visit and primary symptoms?

    This guides triage and ensures the right team sees you first. Clear chief-complaint details reduce delays and help clinicians set a safe plan of care.

  2. Do you consent to evaluation and treatment by our clinicians today?

    Stating consent up front prevents confusion and supports compliance. It also records your preferences if the scope of care changes during your stay.

  3. Who should we contact in an emergency, and who is your preferred healthcare decision-maker?

    Designating contacts helps staff act quickly if your condition changes. It also clarifies who can speak for you if you are unable to consent.

  4. What insurance do you have, and do you authorize us to bill your plan (including Medicare if applicable)?

    Collecting payer details early reduces claim denials and billing surprises. If you use Medicare, the Medicare consent release form authorizes us to share necessary information for billing.

  5. Do you agree to receive care by phone or video if needed?

    This confirms your preferences for remote care and protects your privacy. When telehealth is an option, the Telehealth consent form explains risks, benefits, and expectations.

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