Is the patient intake form template free?

Yes. Every template is free to use. The free plan covers 3 forms and 100 submissions a month, with no credit card required.

What fields are included?

11 fields: Full name, Date of birth, Phone, Email, Address, Insurance provider, and more. You can add, rename, reorder or delete any of them.

Do I need to know how to code?

No. You edit the fields in a drag-and-drop builder and publish with one click. Embedding it on your own site is a copy-paste snippet.

Where do the responses go?

Straight to your FormMaker dashboard, where you can read them individually, search across them, or export the lot to CSV. You can also push them to Google Sheets, Slack or Zapier.

Free Patient Intake Form Template | FormMaker

Create a free online patient intake form. Collect contact, insurance, reason for visit and medications before the appointment. No signup required.

Use this template All templates

Category: Medical
Fields: 11
Price: Free

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About this template

A patient intake form gathers the essentials a clinic needs before a visit — contact and insurance details, the reason for the appointment, current medications, and an emergency contact — so front-desk time goes to care instead of paperwork. This free template lets patients complete intake online ahead of time, giving your team clean, legible information and a faster check-in.

Tips for better responses

Let patients fill this out online before arriving to cut waiting-room time.
Capture insurance provider and member ID so billing can verify coverage early.
Ask for current medications to flag interactions before the appointment.
For clinical use, host on a HIPAA-compliant setup and collect only what you truly need.

What's included

Patient informationsection
Full nameentry
Date of birthentry
Phoneentry
Emailentry
Addressentry
Insurancesection
Insurance providerentry
Member / policy IDentry
Reason for visitsection
What brings you in today?editor
Current medicationseditor
Emergency contactsection
Emergency contact name & phoneentry
I consent to treatment and confirm the above is accurate.yesno

Frequently asked questions

Is the patient intake form template free?: Yes. Every template is free to use. The free plan covers 3 forms and 100 submissions a month, with no credit card required.
What fields are included?: 11 fields: Full name, Date of birth, Phone, Email, Address, Insurance provider, and more. You can add, rename, reorder or delete any of them.
Do I need to know how to code?: No. You edit the fields in a drag-and-drop builder and publish with one click. Embedding it on your own site is a copy-paste snippet.
Where do the responses go?: Straight to your FormMaker dashboard, where you can read them individually, search across them, or export the lot to CSV. You can also push them to Google Sheets, Slack or Zapier.

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