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📋 Form Template

Free Patient Intake Form Template

Collect patient demographics, medical history, and insurance information before the first appointment. A HIPAA-ready online form with 15 customizable fields — streamline your check-in process.

15 Fields
~5 min
Free
AI Auto-Generate
Live Preview
Sample Form Fields
Patient Full Name name
Date of Birth date
Email / Phone email/phone
Insurance Provider input
Medical History checkbox
Consent to Treatment switch
15 fields total · ~5 min to complete

Quick answer

Free patient intake form template for clinics and practices. Collect history, insurance, and signed consent — test-fill the live form, then copy in one click.

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Live Preview

This is the actual running form — not a screenshot. Try it yourself.

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This is the actual intake form your patients will fill out. Responses are collected automatically and securely.
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Who Is This For

Pick your role — see how the form fits your workflow.

1

Healthcare Providers

Streamline patient onboarding by collecting demographics, insurance, and medical history before the first visit. Workflow: Copy template → Customize medical history fields → Share link with new patients → Review intake data before appointment.

2

Clinic Managers

Reduce wait times by sending intake forms to patients digitally before they arrive. Workflow: Import template → Add clinic-specific fields → Send link via email or SMS → Track completed submissions in real time.

3

Mental Health Professionals

Collect background information, current concerns, and consent before the initial session. Workflow: Customize template for therapy-specific fields → Share securely → Review responses to prepare for the session.

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Sample Questions Inside

A preview of real questions from this template — the full version adds scoring logic, branching and a personalized report per respondent.

  1. Date of birth (date)
  2. Insurance provider & member ID (text)
  3. Government ID number (text)
  4. Existing medical conditions (multi-select)
  5. Current medications (text)
  6. Known allergies (text)
  7. Emergency contact (name + phone)
  8. I consent to treatment and data handling. (checkbox)
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Frequently Asked Questions

What is a patient intake form?
A patient intake form is an online document used by healthcare providers to collect patient demographics, medical history, insurance information, and consent before a first appointment. It streamlines the check-in process and ensures accurate medical records.
Is this patient intake form template free?
Yes. Click "Use This Template" to copy the full form into your FormLM workspace for free. No credit card required.
Can I customize this form template?
Absolutely. After copying, you can add, remove, or modify fields, change the design, and adjust settings to match your clinic's specific requirements.
What fields should a patient intake form include?
A comprehensive patient intake form should include: patient name, date of birth, gender, contact information, address, emergency contact, insurance details, reason for visit, current medications, allergies, medical history, and consent to treatment.
Is the data collected through this form secure?
Yes. FormLM uses encrypted connections and secure data storage. You can configure your form to comply with HIPAA requirements for protected health information.

Streamline Patient Onboarding Today

Copy the Patient Intake Form into your workspace, customize it for your practice, and share it with patients. Free to start.