Send the form before the appointment
Email the intake form link when confirming the appointment. Patients complete it at home, at their own pace — which results in more complete and accurate information than rushed waiting room paperwork.
Free template · 14 fields included
Medical Intake Form Template
Collect patient information, insurance details, medical history, medications, and allergies before the appointment. Reduce wait times, improve preparation, and give your clinical team the context they need before the patient arrives.
No credit cardFree forever planCustomizable fields
Fields included
14 pre-built fields, ready to customize.
#
Field label
Type
Required
1
Patient Full Namee.g. Jane Smith
Short text
Yes
2
Date of Birthe.g. YYYY-MM-DD
Short text
Yes
3
Email Addresse.g. jane@email.com
Email
Yes
4
Phone Numbere.g. (555) 000-0000
Phone
Yes
5
Gender
Radio (single choice)
No
6
Insurance Providere.g. e.g. Blue Cross, Manulife
Short text
No
7
Insurance Policy Numbere.g. Policy or member ID
Short text
No
8
Reason for Visite.g. Briefly describe your symptoms or reason for the appointment...
Long text
Yes
9
Current Medicationse.g. List all medications and dosages, or write 'None'
Long text
Yes
10
Known Allergiese.g. Medications, foods, environmental, or write 'None'
Long text
Yes
11
Do you have any chronic conditions?
Radio (single choice)
No
12
Chronic Conditions (if any)e.g. Diabetes, hypertension, asthma, etc.
Long text
No
13
Emergency Contact Namee.g. Full name
Short text
Yes
14
Emergency Contact Phonee.g. (555) 000-0000
Phone
Yes
All fields are fully customizable — add, remove, or reorder after opening the template.
Use cases
Who uses this template.
General practitioners and family medicine clinics
Specialist offices collecting pre-appointment history
Physiotherapy, chiropractic, and allied health intake
Telehealth platforms collecting patient context
Best practices
How to get the most from this form.
Make insurance optional if not always required
Not all patients have insurance or need to provide it. Mark insurance fields as optional to avoid blocking submissions from self-pay patients.
Use explicit instructions for medication fields
The 'Current Medications' field should specify the expected format: drug name, dosage, and frequency. A placeholder like 'Metformin 500mg, twice daily' reduces ambiguous responses.
Clearly state your data handling practices
Include a brief privacy note in the form's description or confirmation message. Patients need to know how their health information is stored and who can access it.
FAQ
Common questions.
What should a medical intake form include?
A standard medical intake form should collect: Patient name, Date of birth, Contact info, Insurance details, Reason for visit, Current medications (with dosages), Known allergies, Chronic conditions, and Emergency contact. This template covers all of these.
Is Formiqa HIPAA compliant?
Formiqa is not HIPAA-compliant. For healthcare practices that handle Protected Health Information (PHI) under HIPAA regulations, use a HIPAA-certified platform such as JotForm's HIPAA plan or a dedicated EHR intake solution. This template is suitable for general wellness, physiotherapy, or contexts where HIPAA doesn't apply.
Can patients fill this out on their phone before the appointment?
Yes. Formiqa forms are fully mobile-responsive. Send the form URL in your appointment confirmation email and patients can complete it on any device.
How are patient files stored?
Uploaded files (ID, insurance cards, etc.) are stored on Cloudflare R2 — encrypted at rest. Only your Formiqa account can access the files. Files are downloadable from your submission dashboard.
Can I use this for telehealth intake?
Yes, with a caveat about HIPAA compliance noted above. For general telehealth wellness or non-regulated contexts, this form collects the context needed before a video consultation.
Use this template for free.
All 14 fields included. Customize and publish in minutes.
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