Intake & onboarding
Patient intake
A new-patient form for clinics and practices: personal details, emergency contact and insurance, then medical history, medications, allergies and consent.
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 and 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) and 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
Add, remove or reorder questions in the builder; every change is tracked and nothing goes live until you publish. Pick a design preset or your own colours, add your logo, and share the link or embed the form on your site.
