Patient Intake Form Template

Hi there. Let's walk you through the intake process.Let's start with your first name.And what's your last name?What's your date of birth, {{field:01F79A4AZS476X13D9T4T8EMKM}}?Who's your emergency contact?Please give us their full name.What's their phone number?What will you be treated for?Almost done! What's your insurance number?Thanks {{field:01F79A4AZS476X13D9T4T8EMKM}}, you're all set.

Collect up to 3.5x more data with Typeform

Make your patients feel at ease from the word go

Old school forms are cold and complicated. Help your patients navigate through their intake process with a friendly form that feels like it was made just for them. Our time-saving integrations allow you to focus on what matters.

With Typeform, you can customize everything

Change text, colors, and even logos to match look and feel of your brand. Then embed forms smoothly onto web and email.

Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.

Stay efficient by connecting forms to your workflow. Typeform integrates with 120+ tools including Slack, Zapier, and HubSpot.

Patient intake form FAQs:

Make it more human—but also keep it time-efficient. This patient intake form template shows you how to make a form feel like a conversation. By asking one question at a time, you help your patients focus.

It’ll help them give thought-through answers and leaves little room for confusion. And things like recalling their name in follow-up questions makes the whole process feel more personal. A little goes a long way.

We hear you. Let’s start by cutting out the copy-pasting data from paper forms or PDFs into spreadsheets or patient files. Our smart integrations will automate this for you.

Like magic, all the data will appear in the right place—so you can focus on other tasks. You can automatically create Google Docs, store responses neatly in Dropbox. Any follow-up forms needed based on a patient's questions? We can arrange that as well.

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.