Patient Intake Form Template

Home / ... / Patient Intake Form Template

Available on a Paid Plan

Looking to collect patient data effortlessly? Easily gather the information you need from new and returning patients using this patient intake form template.

Use Template

Show more templates

About this template

As a healthcare provider, you want to collect patient data effortlessly and not waste time on the daily paperwork. Use the patient intake form template to easily gather all the information you need from new and returning patients, such as their health history, insurance, previous medication, demographic data. With the online patient intake form, you can create appointments without dealing with printed forms and improve the intake process. Customize this patient intake form template as you see fit using our form builder.

Frequently Asked Questions

What are patient intake forms?

A patient intake form is a document used by medical organizations (hospitals, clinics) to gather contact and medical information about the patient before their appointment.

How do I create a medical intake form?

Creating a medical intake form with 123FormBuilder is a no-brainer.
Step 1. Use our patient intake form template.
Step 2. Scan at the already existing fields to understand if they cover all your needs.
Step 3. Use the drag and drop to customize it and adapt it to your healthcare institution
Step 4. Make sure to mark as mandatory the fields asking for crucial data (contact details, emergency contact, medical history, vaccinations, etc.)
Step 5. Add your branding elements (no code skills are needed) and share the form.

If you handle protected health information and need to safeguard it in the United States, 123FormBuilder provides HIPAA-compliant protection for forms that you can opt for on a higher subscription plan.

Customize template

Need a patient intake form template for your healthcare practice? This sample form can be modified according to your specifications and maintained with absolutely no need for coding. Radio buttons, Likert scales, signatures, checkboxes are all available in the easy, drag-and-drop editing tools provided by 123FormBuilder. Take complete ownership of the design, too, with your choice of colors and fonts and the ability to split the form into multiple pages.

Publish template

It’s easy to post your patient intake form on your website. This way, incoming clients can fill it out at home before they arrive. Just copy and paste one short snippet to a page and you’re done! In addition, you can send a link by email or post to social media using the convenient share buttons. The mobile-responsive patient intake form is easy to use on displays of all sizes, from smartphones and tablets to laptops and oversized monitors.

Collect & manage data

Store and organize all patient intake form data securely in your private 123FormBuilder database, where you’ll find a variety of tools to make use of form data. For one, you can export records as PDFs to print a copy for the physician to review. Second, the records can also be saved as an Excel file or CSV for use in patient management software. You can also generate charts and graphs to study patient demographics. Many app integrations are also available, including Dropbox, Smartsheet, and MailChimp.

Optimize processes

Using an online patient intake form can save time and trouble in all phases of care. Filling out the form in advance allows doctors to be better prepared than they would if a paper form is filled out in the office. Furthermore, delays caused by patient paperwork can snowball into longer and longer wait times for patients as the day goes on. Last but not least, custom notifications and exportable data eliminate most of the need for data entry, reducing the potential for hazardous errors in patient records.

Start with this template