New Patient Intake Form Template
A general medical clinic uses this form to collect new patients’ contact details, health history, medications, allergies, insurance information, emergency contacts, and consent.
When to use it
- Before a patient’s first appointment
- When updating a new patient’s chart before a visit
- When a clinic needs insurance and emergency contact details
- When collecting health history and consent in advance
What it asks
- What is your full name?
- What is your email address?
- What is your phone number?
- What is your home address?
- What is your date of birth?
- What is the reason for your visit?
- Is there any medical history you’d like us to know?
- What medications do you currently take?
- Do you have any allergies?
- Upload a photo of your insurance card
- What is your emergency contact’s name?
- What is your emergency contact’s phone number?
- What is your relationship to your emergency contact?
- I consent to the clinic using the information I provide to support my care and contact me about my visit.
Why it should be encrypted
This form includes identifying details, health information, and an insurance card image. Only clinic staff who need the information for care or appointment contact should be able to read it.
Tips
- Tell patients which clinic staff can access their answers and how the information will be used.
- Make the insurance card upload optional if patients can provide it another way.
- Review the medical history and allergy questions to match your clinic’s intake process.