Pediatric Patient Intake Form Template

Collects a child’s contact, birth, immunization, allergy, development, and school details from a parent or guardian for a pediatric care team.

Use this template free

When to use it

• Before a child’s first pediatric appointment
• When updating a returning patient’s health history
• Before a developmental or milestone assessment
• When transferring a child’s care to a new clinic

What it asks

1. Parent or guardian full name
2. Email address
3. Phone number
4. Child’s full name
5. Child’s date of birth
6. Please share any relevant birth history
7. What is your child’s immunization status?
8. Please share any immunization details you’d like us to know
9. Does your child have any known allergies?
10. If yes, please list the allergies and any reactions
11. Are there any developmental milestones or concerns you’d like to share?
12. School or childcare name
13. Grade or class
14. I confirm I’m authorized to provide this information and consent to its use for my child’s care.

Why it should be encrypted

A child’s health history, allergies, contact details, and school information are personal and sensitive. Encryption helps keep answers unreadable to SealForm and limits access to the intended care team.

Tips

• Tell parents which details are required and which they can skip.
• Add a secure way to share immunization records if needed.
• Review who can access submitted responses and remove access when it’s no longer needed.

More Healthcare templates

• Appointment Request Form
• Authorization to Release Medical Records
• Chiropractic Intake Form
• Current Medications Form
• Dermatology Intake Form
• Insurance Information Update
• Medical History Form
• New Patient Intake Form

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