Patient intake

What is in the form

Page 1: About you

• First name
• Last name
• Date of birth (date)
• Sex (dropdown)
• Email
• Phone
• Home address (address)
• Emergency contact
• Their phone
• Insurance provider
• Policy or member number
• Your regular doctor or practice, if any

Page 2: Medical history

• What brings you in? (long answer)
• Have you been diagnosed with any of these? (pick any)
• Current medications and supplements (long answer)
• Allergies (long answer)
• Past surgeries or hospital stays, with approximate dates (long answer)
• Do you smoke? (one of 4)
• Alcohol (one of 4)
• Are you, or could you be, pregnant? (yes or no)
• I consent to examination and treatment, and confirm the information above is accurate. (yes or no)
• I have read the practice’s privacy notice and agree to my information being used to provide my care. (yes or no)

It opens with a welcome screen (“New patient form”) and ends with a thank-you message you can edit.

After someone submits

This template comes without a workflow. Responses land in your dashboard, and you can add a step in the workflow editor: an approval by email, a post to Slack or Teams, a row in Notion or Airtable, or a webhook.

Make it yours

Change anything in the builder: nothing goes live until you publish.