The Patient Information Form Template from WPForms is an essential tool, designed to gather comprehensive patient details quickly and securely. This medical form is entirely customizable and can be edited to fit any business need.
What’s A Patient Information Form?
A patient information form is a mandatory medical form for each patient and is required by most healthcare facilities. This medical form’s purpose is to collect the patient’s information and demographics before their appointment.
- Patient Details: This section collects essential patient information, such as:
- Date of the form submission.
- Patient’s full name for proper identification.
- Date of birth to determine the patient’s age.
- Sex, providing vital information for healthcare services.
- Email address for electronic communication.
- Cell phone, home phone, and work numbers for multiple contact options.
- Permission for leaving messages, ensuring patient privacy.
- Mailing address for correspondence or billing purposes.
- Information about the patient’s current or previous occupation.
- Marital status, which can be relevant for health records.
- Reason for the appointment, guiding the healthcare provider’s preparation.
- Emergency Contact Information: This critical section includes:
- Emergency contact’s name for urgent situations.
- Contact number to reach the emergency contact.
- Relation to the patient, providing context for the contact.
- Current healthcare provider details.
- Permission to send information to the healthcare provider, ensuring coordinated care.
- Insurance Provider: Vital for billing and insurance claims.
- Group number and ID number for insurance identification.
- Subscriber information.
- Employer details for employment-related coverage.
- Date of birth.
- Relationship of the subscriber to the patient.
- Final Steps: To enhance the service experience, this section asks:
- How the patient heard about the facility, aiding in marketing analysis.
- Space for additional questions or comments, allowing patients to share more specific information or concerns.
Check out this guide for more information on intake form examples related to the healthcare industry and other businesses.
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By using our patient information template, you can quickly customize it to fit your requirements and embed it onto your website. It will allow patients to securely submit the form details before their appointment, resulting in a streamlined process.
Don’t forget to edit the email confirmation settings to notify the patient their details have been received. Also, feel free to customize the template to suit your specific needs with WPForms’ intuitive drag-and-drop form builder.
Get the Patient Information Form Template today and transform the way your facility manages patient information, leading to improved efficiency and patient satisfaction.
