Healthcare

Patient Intake Form Template

Have new patients complete their paperwork before they arrive. Shorter waiting-room queues, legible answers and records your team can search.

Use this template — freeTry it first
18 questions
4 pages
~6 min
To fill in
Steps layout
Mobile-ready
Free
No credit card
Patient intake form below a photo of nurses at a clinic front desk

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Photo by RDNE Stock project on Pexels

Who it's for

Clinics, dental practices, physiotherapists, therapists and wellness centres registering new patients.

  • New-patient registration before the first visit
  • Dental and physiotherapy intake
  • Telehealth appointment intake
  • Annual health-record updates

What this template asks

Every question can be changed, removed or reordered once it's yours.

Patient details

  1. First name*

    Short text

  2. Last name*

    Short text

  3. Date of birth*

    Date

  4. Gender

    Dropdown

    • Female
    • Male
    • Non-binary
    • Prefer not to say

  5. Phone*

    Phone number

  6. Email*

    Email

  7. Home address

    Long text

Insurance

  1. Insurance provider

    Short text

  2. Policy or member number

    Short text

  3. Photo of insurance card

    File upload

    Front and back, optional

Medical history

  1. Reason for your visit*

    Long text

  2. Do you have any of these conditions?

    Checkboxes

    • Asthma
    • Diabetes
    • High blood pressure
    • Heart disease
    • Thyroid disorder
    • None of these

  3. Current medications and doses

    Long text

  4. Allergies

    Long text

    Medicines, foods, latex or other

  5. Do you smoke?

    Multiple choice

    • Never
    • Former smoker
    • Current smoker

Emergency contact and consent

  1. Emergency contact name*

    Short text

  2. Emergency contact phone*

    Phone number

  3. Consent*

    Checkboxes

    • I consent to treatment and to the clinic storing my information

Tips for more responses

  1. 1

    Send the link with the appointment confirmation so patients fill it in at home.

  2. 2

    Check your local health-privacy rules (for example HIPAA or GDPR) before collecting medical information online.

  3. 3

    Limit who in your workspace can view responses with form permissions.

Questions

Where is patient data stored?

Responses are stored in your Dculus Forms workspace and uploaded files in private storage. For full control, self-host Dculus Forms and keep every record in your own database.

Can patients upload their insurance card?

Yes. The insurance step includes an optional file upload for a photo of the card.

Is this patient intake form template free?

Yes. Copy it into a free Dculus Forms account, change anything you like and start collecting responses. No credit card is needed.

Can I change the questions?

Yes. Your copy opens in the form builder, where you can add, remove and reorder questions, change the layout and add your own branding.

Where do the responses go?

Responses arrive in your Dculus Forms workspace. You can export them to Excel or CSV, send them to Google Sheets or a webhook, and get email notifications.

Can I host it myself?

Yes. Dculus Forms is open source (GPLv3), so you can run it on your own servers and keep every response in your own database.

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