Patient Intake Form Template

Using the patient intake form is essentially a medical onboarding form. It asks a patient to provide essential information to help the medical institution properly register them. 

Check out the patient intake form below:

Form Preview

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PATIENT DETAILS

Please tick all that apply

EMERGENCY CONTACT INFORMATION

INSURANCE PROVIDER

FINAL STEPS

What’s in Our Patient Intake Form?

We’ve kept our form only to include the essentials:

  • Patient details
  • Emergency contact information
  • Current healthcare provider
  • Insurance details
  • Market research (how the patient heard about you)
  • And a space to add any extra notes

The beauty of a WPForm template is that they’re fully customizable. Tailor your patient intake form and include a section to determine the patient’s current health status and ask them to provide payment details.

Use This Template