Add this patient demographic form template to your website with 123FormBuilder. Edit the template with simple drag & drop, no coding skills needed.

Customize template

A patient demographic form template can help you get started collecting demographic information about your patients. Start with our pre-made form sample, which asks for info such as name, birthdate, marital status, race, contact info and more. Then customize the template to gather any other information you need in single- or multiple-choice questions, dropdown menus and more. Understanding patient demographics can help you serve your patient population better. In addition to customizing form fields, you can also change the form look and feel with pre-designed themes or your own custom CSS.

Publish template

Publish your patient demographic form to your website or social media presence, or send a link to patients by email. For full optimization, connect your form to your web publishing platforms, such as Facebook, Joomla, Blogger or WordPress, so you can easily publish form information to your existing web presence and give easy access to patients. Forms are mobile friendly so patients can fill them out from anywhere, even the waiting room.

Collect & manage data

Gather patient demographic data from your demographic data form and store it securely in an online dashboard, or export the information to Excel, CSV or PDF files. Even better, connect your patient demographic data form to the other systems you use to run your medical practice – check our 30+ integrations, so you can securely connect data across systems. Of course, HIPAA compliance is available upon request to help protect patient information.

Optimize your flow

Optimize your patient demographic data workflow with instant email or SMS alerts when a patient demographic form is submitted, so you know right away that you have new information on file. Digitizing your workflow will help you process patient demographic data successfully.