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 Demographic Information Form Template

Streamline Patient Data Collection with Our Template

Collecting accurate patient information can be a daunting task for healthcare providers. This patient demographic information form template is designed for clinics and hospitals to streamline the process, ensuring you gather essential details efficiently. With customizable fields for personal data, contact information, and health metrics like pulse and heart measurements, this form helps improve patient data management, enhances record accuracy, and saves administrative time. Plus, it's easy to tailor the template to meet your unique requirements. Experience the benefits of a ready-to-use solution.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
If self-describing gender, please specify
If self-describing pronouns, please specify
Pronouns
She/her
He/him
They/them
Use my name only
Prefer to self-describe
Prefer not to say
Mobile phone
Email address
Preferred contact method
Phone call
Text message
Email
Postal mail
No preference
Is it okay to leave a voicemail with appointment details?
Yes
No
Street address
City
State/Province
ZIP/Postal code
Country
Race and ethnicity (select all that apply)
If self-describing race or ethnicity, please specify
Primary language
Please Specify:
If other language, please specify
Do you need an interpreter?
Yes
No
Marital status
Single
Married
Partnered
Divorced
Widowed
Prefer not to say
Insurance carrier (if applicable)
Member ID
Group number
Policyholder name (if not the patient)
Policyholder date of birth
Insurance coverage status
Private or commercial insurance
Medicare
Medicaid
Tricare or military
Uninsured or self-pay
Prefer not to say
Other
Please Specify:
Emergency contact full name
Emergency contact relationship to patient
Spouse/Partner
Parent
Child
Sibling
Friend
Caregiver
Other
Please Specify:
Emergency contact phone
Primary care provider name
Primary care provider phone
Preferred pharmacy (name and location)
Permission to discuss medical information with this contact
Yes
No
Accessibility or assistance needs (select all that apply)
Please Specify:
If other accessibility needs, please describe
Preferred time of day for contact
Morning
Afternoon
Evening
No preference
I consent to receive appointment reminders via text or email
Yes
No
I confirm the information provided is accurate to the best of my knowledge
Yes
No
Name of person completing this form
Date
Relationship to patient
Self
Parent/Guardian
Spouse/Partner
Caregiver
Other
Please Specify:
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, Sex assigned at birth","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing a patient demographic information form template for FormCreatorAI article

When to use this form

Use this form when you register new patients, update records at annual visits, or correct outdated contact or insurance details. Front desk staff, billing teams, and clinicians all benefit from clean data that matches IDs and payer files. In private practices, community clinics, and telehealth, it speeds intake, prevents duplicate charts, and reduces claim denials. Pair it with the New patient information form to capture visit-specific details, and add the Medical summary form when you need current conditions, medications, and allergies on file. Physical therapy clinics can pre-collect basics here before the Physical therapist evaluation form. The result is fewer back-and-forth calls, faster eligibility checks, and a smoother first visit.

Must Ask Patient Demographic Information Questions

  1. What is your legal name (as on your ID), your preferred name, and your pronouns?

    Your legal name ensures a precise match with identification and insurance systems. Preferred name and pronouns help staff address you correctly and avoid errors in communication.

  2. What is your date of birth and your sex assigned at birth?

    These details help match records and guide age- and sex-specific care, screenings, and dosing. If you also need background conditions tied to age or sex, use the Patient demographics and history information form.

  3. What is your current home address and the best phone number and email to reach you?

    Accurate contact info ensures reminders, billing, and follow-up reach you without delays. It also supports coverage checks that depend on service location and county.

  4. Who should we contact in an emergency, and what is their phone number and relationship to you?

    An emergency contact lets providers reach someone fast if we cannot reach you. The relationship helps staff gauge consent and the type of support they can provide.

  5. What health insurance plan do you have, and what are your member ID and group number?

    Collecting plan and ID details up front enables real-time eligibility and clean claims. This prevents coverage surprises and speeds authorizations when needed.

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