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Patient Intake Form

A patient intake form is a document to collect medical details about the patient, such as genetic illnesses, symptoms, and past operations. By creating an online intake form on, you can easily automate the data collection and save time. Plus, it is possible to have your form thanks to’s free patient intake form template. So, get started now and create your custom form today!

What is a patient intake form?

A patient intake form is a type of inquiry form that is filled out by a new patient when they first arrive at a healthcare facility. It is mostly created by health care providers to get information such as the patient's name, contact information, insurance information, and other relevant details. The form helps clinics to ensure that the patient's records and medical information are accurate and up-to-date.

Patient intake forms are an important part of the patient's medical record. And a patient intake form can be paper or digital, and they vary in detail depending on the facility. But creating a medical intake form online will bring you many advantages, such as being able to access them all the time or allowing patients to fill them out before coming to the clinic.

Why use an online patient intake form?

A patient intake form is an essential document to get personal information from a patient and learn about their medical history. However, it can be time-consuming to give out, collect, and store paper forms. They will be hard to find when we look for them, as well. The solution is online patient forms. Using online forms will help you save time and collect all the information automatically. Additionally, this patient intake form template comes with all the standard questions and will make the process faster.

What should you ask in a patient intake form?

When creating a patient intake form or a patient registration form, it is vital to ask for all the relevant information. On, you can find numerous form fields to ask and collect the information you need. It is also possible to collect files, images, or other documents with an upload field. To help you get an idea, here are some of the details you may ask from your patients:

  • Personal information
  • Address 
  • Phone number 
  • Insurance company 
  • Name of primary care physician (PCP) 
  • Reason for visit 
  • History of present illness (HPI) 
  • Past medical history (PMH) 
  • Medications (Current and Previous) 
  • Allergies 
  • Family history 

Create online forms with ease, customize your form’s fields, design, and privacy options within a couple of minutes. By adding some of many types of form fields for all needs with’s drag and drop form creator screen, you can also create online surveys and exams. 

Powerful features: 

  • Conditional logic 
  • Create forms with ease
  • Calculator for exams and quote forms
  • Geolocation restriction
  • Real-time data
  • Detailed design customization

You can integrate the forms and surveys you created on with many third-party applications via's direct integrations and Zapier. These applications and integrations include creating or modifying a sheet on Google Sheets every time your form is submitted and creating a deal on Pipedrive for an order you received or a generated lead. 

There are no limits and boundaries when it comes to creating online forms, surveys, and exams with! You can choose one of many types of templates, create a form, and get started right away! Once you start with a template, you can easily customize your form fields, form design, and many other attributes!

You can share your forms in any way you like. If you want to share your form and collect responses through your form’s unique link, you can simply adjust privacy settings and copy-paste your form link anywhere. And if you would like to embed your form in your website, you can easily copy and paste embed code in your website HTML.

On, you can customize your form’s theme and design elements in depth. Once you switch to the ‘Design’ tab after getting your form done, you will see many different design customization options. You can change your form theme by choosing your own colors or picking one of many ready-made themes.