Patient intake form builder
Put together a new patient intake form for your practice in a few minutes. Pick your specialty and the sections you need, change any question, and download a PDF ready to print or hand out.
The form covers contact details, the reason for the visit, medical history, medications and allergies, consent to treatment, and the patient's acknowledgment of your privacy notice.
Build your form
Optional. The PDF has no patient details: patients fill it in by hand.
Edit the wording
Change any heading, question or paragraph. Text in [brackets] is for you to fill in.
Answers: Phone call · Text message · Email
Answers: Yes · No
Answers: Friend or family · Referred by a doctor · Internet search · Social media · Other
Answers: Never · I used to · Yes
Answers: Never · Occasionally · Most weeks · Most days
Answers: Rarely · 1–2 times a week · 3 or more times a week
The PDF is made in your browser. Your choices and edits are sent only if you sign up, to set up the form in your new account.
Use this form online
Start a free CloudMedico trial and this form, with your edits, is waiting in Patient Forms. Send it from a patient's Documents tab: they fill it in and sign it on their phone before the visit, and the signed PDF goes on their record.
Patient forms in CloudMedico
- Start from this form, or from the intake, medical history and consent templates, and change any question.
- Send a form from the patient's Documents tab, to fill in or to fill in and eSign.
- Patients complete it in the Patient Portal on a phone, tablet or computer, with nothing to download.
- The answers and a signed PDF are saved on the patient's record, encrypted, and the staff member who sent it gets an email.
- Patient forms are in every plan, including the free trial.
What a patient intake form should cover
An intake form gives you what you need before the first visit: who the patient is, how to reach them and someone close to them, why they are coming, and the medical history that affects safe treatment.
- Contact details and an emergency contact.
- The reason for the visit, when it started and earlier treatment.
- Conditions, medications, allergies, surgeries and injuries.
- Questions for your specialty: pain and warning signs for physical therapy and chiropractic, what brings the client for counseling, dental history for dentists.
- Consent to examination and treatment, and the patient's signature.
- An acknowledgment that the patient received your privacy notice.
The privacy notice acknowledgment
In the US, HIPAA asks providers who treat patients directly to make a good-faith effort to get a written acknowledgment that the patient received the Notice of Privacy Practices, no later than the first visit except in an emergency, and to record why when they can't (45 CFR 164.520(c)(2)). HIPAA doesn't require consent to use health information for treatment, payment or health care operations (45 CFR 164.506).
In the UK, practices give patients a privacy notice under the UK GDPR (Articles 13 and 14). Health data used to provide care is processed under Article 9(2)(h) with the Data Protection Act 2018, so it doesn't rest on the patient's consent either; the form records that they received the notice.
Consent to treatment
A signed form records consent; it doesn't replace the conversation. In the UK, the Supreme Court's Montgomery ruling (2015) and the GMC's guidance on decision making and consent (2020) expect you to discuss the material risks of a treatment and its reasonable alternatives. In the US, informed consent is set by state law and your licensing board. Edit the consent wording to describe what you do.
Questions and answers
Is this patient intake form free?
Yes. Build the form, edit the wording and download the PDF without an account.
Does the PDF include any patient details?
No. The PDF is a blank form for patients to fill in by hand. It is made in your browser, and you can add your practice name at the top.
Can patients fill in the form online?
Yes, in CloudMedico. Select Use this form online and start a free trial: the form you built is in Patient Forms, ready to send. The patient fills it in and signs it in the Patient Portal on a phone, tablet or computer, and you get their answers and a signed PDF on their record.
Do I need a separate consent form?
This form includes consent to examination and treatment. For a procedure with significant risks, use a consent form that describes that procedure, its risks and its alternatives, and discuss it with the patient.
Is this legal advice?
No. The wording is a starting point based on the sources below. Check it against your state's or country's rules and your professional body's guidance before you use it.