New Patient Intake Form
Registration essentials, history highlights, consent, and a signature – before the first visit.
8 questions · 1 page · about 5 minutes to answer · fully editable after you start
Clipboard paperwork in the waiting room is the worst first impression in healthcare. This digital intake collects the essentials before the appointment: contact details, the reason for the visit, current medications and allergies, and a signed acknowledgement with the date – so the first minutes of the consultation go to the patient, not the form.
Send it automatically with the booking confirmation. The signature is drawn on any device and stored with the response, and the whole submission is readable by the clinician in under a minute.
Template preview
This is a picture of every question as a respondent would see it, so nothing on it can be clicked or typed into. Use this template to get your own editable copy.
Opens in the Light theme, or in your own default theme if you have set one — change it anytime to any of the 4 built-in looks, or build your own on a paid plan.
Page 1
Before your first visit
Welcome. This form collects the details we need to set up your record before your first visit, so that less of your appointment is spent on paperwork. It takes about 5 minutes. This form is not an emergency service. If you need urgent medical help, call your local emergency number.
Q1.Full name and date of birth*
Q2.How we can reach you*
Q3.How would you prefer us to contact you?*
- Phone call
- Text message
Q4.What brings you in? Briefly describe your main concern.*
Q5.Current medications and known allergies (write None if none)*
Q6.Have you been treated at this clinic before?
- No, first time
- Yes, in the past year
- Yes, more than a year ago
Q7.Today's date*
Q8.Sign to confirm the information above is accurate*
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