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Patient Intake Form Template

Streamline Your Patient Registration Process with Ease

Managing patient information can be tedious and time-consuming, but our Patient Intake Form Template simplifies the process for you and your practice. Designed for medical professionals, this template helps you collect vital patient information smoothly and efficiently, ensuring a seamless check-in experience. Enjoy benefits like secure data collection, easy telemedicine integration, customizable fields for specific needs, and HIPAA-compliant features. Explore how this template can enhance your patient onboarding today.

Use this Template (FREE) Live Preview
Full legal name
Date of birth
Sex assigned at birth
Female
Male
Intersex
Prefer not to say
Street address
City
State/Province
Postal code
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Email address
Mobile phone
Preferred contact method
Phone call
Text message
Email
No preference
I consent to receive appointment reminders by text and/or email
Yes
No
Emergency contact full name
Emergency contact phone
Relationship to you
Spouse/Partner
Parent/Guardian
Child
Sibling
Friend
Other
Please Specify:
Do you have health insurance?
Yes
No
Insurance company name
Member/Policy ID
Policyholder name (if not you)
Policyholder date of birth
Permission to bill your insurance for covered services
Yes
No
Primary reason for visit today
Ongoing medical conditions (select all that apply)
Please Specify:
Past surgeries or hospitalizations (with approximate dates)
Accessibility or accommodation needs
Family history of major illnesses (select all that apply)
Please Specify:
Current symptoms (select all that apply)
Please Specify:
Are you currently pregnant or think you might be?
Yes
No
Not applicable
Prefer not to say
Tobacco use
Never
Former
Current
How often do you drink alcohol?
Never
Rarely
Sometimes
Often
Always
Current medications and doses (include over-the-counter and supplements)
Allergy details and reactions
Allergies (select all that apply)
Please Specify:
Primary care provider name
Preferred pharmacy (name and location)
I consent to evaluation and treatment by this practice
Yes
No
I authorize the practice to obtain, use, and disclose my health information for treatment, payment, and healthcare operations
Yes
No
I acknowledge that I have received or had access to the Notice of Privacy Practices
Yes
No
I accept financial responsibility for charges not covered by my insurance
Yes
No
Type your full name to sign
Date
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Paper art illustration depicting a patient intake form for FormCreatorAI article

When to use this form

Use this form when you need fast, accurate check-ins for new or returning patients. It fits front-desk intake at clinics, dental practices, and urgent care, and also pre-visit digital intake forms sent by text or email. You capture identity, contacts, insurance, and consent, then route patients to the right provider without repeated paper. Teams benefit from fewer waiting room bottlenecks, cleaner charts, and fewer billing errors. For deeper background, pair it with the Patient demographics and history information form. After the visit, send a brief Patient satisfaction questionnaire form to close the loop and improve service. The result is safer care, shorter waits, and fewer follow-up calls.

Must Ask Patient Intake Questions

  1. What is your full legal name, date of birth, and contact information?

    This verifies identity, matches records, and ensures alerts reach you. It also reduces duplicate charts and delays during check-in.

  2. What brings you in today, including your main symptoms, onset, and severity?

    Stating the reason for your visit helps triage and sets the right appointment length. Onset and severity guide urgency and initial testing.

  3. Do you have any allergies or adverse reactions, especially to medications, latex, or foods?

    Allergy details prevent harmful orders and help staff prepare. Listing reactions (for example, rash or anaphylaxis) improves clinical decisions.

  4. What medications, supplements, and doses are you currently taking?

    A complete list avoids interactions and duplications. If you have complex history, you can add a concise overview with the Medical summary form.

  5. Do you have past diagnoses, surgeries, or family conditions we should know about?

    History reveals risks that affect testing and treatment. For ongoing tracking or screening, you can use the Patient health questionnaire form.

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