Patient information form template

About this patient information form

A patient information form registers a new patient at a clinic, dental practice, physiotherapy centre or diagnostic lab: personal and contact details, insurance or payment, an emergency contact, the reason for the visit and a short medical summary, with consent to treatment and to the practice’s privacy policy.

For a full health background, pair it with the medical history form. Everything you type stays on your device: the form is built in your browser and nothing is uploaded.

What’s on the patient information form

The template has 5 sections and 20 questions. Every one can be renamed, moved or deleted.

• Patient: Full name; Date of birth; Sex (choose one: Female, Male, Other); Phone; Email; Address; Occupation; Preferred language
• Insurance and payment: Payment (choose one: Self-pay, Insurance, Corporate, Government scheme); Insurer and policy number; Policy holder (if not patient)
• Emergency contact: Name; Relationship; Phone
• Today’s visit: Reason for visit; Referred by; Current medications; Allergies
• Consent: Agreement: “I consent to examination and treatment and have read the clinic’s privacy notice.”; Patient or guardian signature with date

Tips

• Send the fillable PDF before the appointment to cut waiting-room time.
• Add your clinic’s registration number and address in the form header.
• Check the form against your local health-data rules before using it.

Four ways to save it

A fillable PDF has typing boxes, tick boxes and choices built in. A printable PDF gives clean boxes and writing lines for pen and paper. The Word file can be edited further, and the HTML code adds the same questions to a website. Browse more form templates, or design a completely different layout in the custom form builder.