Templates Health & Wellness Medical Intake Form Template

Medical Intake Form Template

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Patient Name
Can We Leave a Message?
Please tick all that apply
Mailing Address


Emergency Contact's Name


Do you want to easily register medical patients online? If so, then you need the Medical Intake Form from WPForms.

Using this intake form is essential for medical onboarding. It asks the form user to provide crucial information to help the medical establishment properly register the user.

What Goes Onto a Medical Intake Form?

On our Medical Intake Form, you’ll find fields for the following basic necessary information:

  • Patient Details: Name, Date of Birth, Sex, Contact Information, Mailing Address, Current or Previous Occupation, Martial Status, Reason for Visit
  • Emergency Contact Information: Name, Number, Relation to Patient, Current Healthcare Provider Information
  • Insurance Provider Details: Group Number, ID Number, Subscriber, Employer, Date of
  • Ample space to include any extra notes

The great thing about all of the form templates from WPForms is that they’re fully customizable. You might decide to edit your own form to include a section to determine the patient’s current medical status, or to ask them to provide payment details.

Plus, you can rest assured that the private information submitted on this form is securely collected and safely stored right on your own website.

Get started with WPForms today to create and customize your own Medical Intake Form. Signing up with WPForms gives you access to this and hundreds of other pre-made templates.