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Patient Name
Patient Email Address
If registering a child, please provide the parent or guardian's email address.
If registering a child, please provide the parent or guardian's phone number.
Has this patient previously been known by another name?

Residency

Patient's Current Address
Is the patient ordinarily resident in the USA?
Can the patient access a local chemist or pharmacy to collect medication?
Patient's Previous Address

Previous Physician Details

Previous Physician Surgery Address
Clear Signature
Please sign to confirm the information provided for registration.
Clear Signature
The patient must sign to confirm that they would like to be added to the UNOS Register(s) selected above.

Do you run a medical practice? When you get new patients, you’ll need a way to sign them up. The standard practice is to use a medical registration form, and with WPForms, you can create one online, using the WPForms’ Medical Office Registration Form Template.

What Healthcare Registration Forms Do I Need?

Healthcare centers, hospitals, and medical practices use several forms to register and process new patients. The medical registration form is possibly the most commonly used one.

A medical office registration form needs to capture a significant amount of information on patients and their payment methods. The WPForms’ Medical Office Registration Form Template does an excellent job of this, using a mix of WPForms’ form fields.

To begin with, there are basic fields like the Name, Email, Phone, and Address fields that help to collect essential patient identity and contact information. On our template, the Name field is set up to use a three-column layout for the patient’s first, middle, and last names.

The Patient Email field has a corresponding Confirm Email field that helps ensure you get the correct patient email address. The rest of the template uses a mix of fields such as the dropdown field, multiple choice field, and so on.

You’ll see a dropdown field, for instance, asking for the patient’s gender. This field is set up with three options, which include Male, Female, and Other. If users choose Other, this will trigger a bit of conditional logic to display a single-line text field where they can specify their gender.

As you’ll see, the Medical Office Registration Form Template is pretty comprehensive and will be a good fit for your medical registration needs. Since this form will primarily be used by internal staff, you may want to use the WPForms’ Form Locker addon to prevent unauthorized access.

Get started with WPForms today to create and customize your medical office registration form. Signing up with WPForms gives you access to this and hundreds of other pre-made form templates.