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Patient Information Form Template

Streamline colleague communication and enhance patient care effortlessly

Collecting accurate patient information can be a challenge, especially during busy office hours. This patient information form template is designed to help healthcare providers gather vital data from new and returning patients efficiently. With this template, you can easily capture essential details like medical history, allergies, and contact information, improve onboarding processes, ensure compliance with healthcare regulations, and enhance patient communication. Feel free to explore the live template and see how it works for you.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
If you selected Prefer to self-describe, please specify (optional)
Pronouns (optional)
Preferred language
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone
Alternate phone (optional)
Street address
City
State/Province
Postal/ZIP code
Country
Preferred contact method
Phone call
Text message
Email
No preference
I consent to receive appointment reminders by text and/or email
Yes
No
Primary insurance provider
Member ID
Group number (optional)
Policyholder full name
Policyholder date of birth
Relationship to policyholder
Self
Spouse
Parent/Guardian
Other
Please Specify:
Secondary insurance provider (if applicable)
Secondary member ID (if applicable)
Do you have secondary insurance?
Yes
No
Emergency contact full name
Emergency contact phone
Relationship to you
Spouse/Partner
Parent/Guardian
Child
Sibling
Friend
Other
Please Specify:
Primary care provider name (optional)
Practice or clinic name (optional)
Provider office phone (optional)
Primary reason for your visit
Preferred appointment date (optional)
Is this visit related to a work injury or auto accident?
Yes
No
Allergies (medications, foods, latex, other)
Current medications and supplements
Past surgeries or hospitalizations (with dates if known)
Ongoing conditions (select all that apply)
Please Specify:
Other conditions (optional)
Tobacco or nicotine use
Never
Former
Current daily
Current occasional
Prefer not to say
Alcohol use
None
Light (1-3 drinks per week)
Moderate (4-7 drinks per week)
Heavy (8+ drinks per week)
Prefer not to say
Are you currently pregnant or breastfeeding?
Pregnant
Breastfeeding
Neither
Prefer not to say
Other family history (optional)
Significant family history (select all that apply)
None
Diabetes
Heart disease
High blood pressure
Stroke
Cancer
Mental health conditions
Other
Please Specify:
Preferred pharmacy name
Pharmacy phone
Pharmacy city
I consent to evaluation and treatment
Yes
No
I authorize billing of my insurance and direct payment of benefits to the provider
Yes
No
I acknowledge receipt of the Notice of Privacy Practices (HIPAA)
Yes
No
I authorize release of information to my listed emergency contact as needed
Yes
No
I understand I am financially responsible for charges not covered by insurance
Yes
No
I consent to the clinic leaving voicemail or secure messages about my care
Yes
No
Patient or guardian printed name
Signature date
If signer is not the patient, relationship to patient
Parent/Guardian
Spouse/Partner
Not applicable
Other
Please Specify:
{"name":"Full legal name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full legal name, Date of birth, If you selected Prefer to self-describe, please specify (optional)","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
paper art illustration depicting a patient information form for FormCreatorAI article

When to use this form

Use this form before your first visit, telehealth session, or urgent care drop-in to capture contact details, demographics, insurance, and consent in one place. It helps your front desk staff verify coverage and emergency contacts while clinicians see key basics at a glance. For full onboarding, pair it with the New patient information form. If the visit centers on a specific concern, add the HPI Form for symptoms and timelines. Specialty clinics can combine this with the Ob gyn patient history form to gather past pregnancies and cycles. The result: faster check-in, fewer billing surprises, and safer care from day one.

Must Ask Patient Information Questions

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

    This ensures your record matches across systems and reduces duplicate charts. It also helps staff address you correctly and avoid insurance delays.

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

    These details confirm your identity and guide age- and sex-based care decisions, dosing, and screenings. Capturing sex assigned at birth supports accurate clinical decisions while respecting your gender identity.

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

    Reliable contact info lets your care team send reminders, forms, and lab results the way you prefer. It also helps them reach you quickly for time-sensitive updates.

  4. Do you have any medication allergies, and what medications and supplements are you currently taking?

    Knowing allergies and current medications prevents dangerous interactions and supports safe prescribing. For a deeper history, add the HIPAA Medical history form.

  5. Who is your health insurance provider, and what are your member ID and group numbers?

    Insurance data allows the clinic to verify eligibility and estimate your costs before the visit. It reduces claim denials and keeps billing surprises to a minimum.

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