Concierge Medicine Intake Form
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Concierge Medicine Intake Form
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The Concierge Medicine Intake Form is designed for concierge medicine practices and direct primary care programs, capturing the thorough health assessment data needed to deliver personalized, proactive care. This template goes beyond standard intake forms to collect patient demographics alongside a comprehensive medical history, detailed family history with multi-generational disease mapping, wellness and longevity goals, lifestyle assessment (nutrition, exercise, sleep, stress management, alcohol and tobacco use), preventive screening history, and care experience preferences. The form reflects the premium, whole-person approach that distinguishes concierge medicine from volume-based primary care.
Built for concierge medicine practices, executive health and wellness programs, direct primary care clinics, and longevity-focused medical practices, this form includes sections for current health concerns prioritized by the patient, complete medication and supplement list, specialist and subspecialist provider directory, mental health and cognitive wellness screening, sexual and reproductive health, travel schedule and immunization needs, health technology usage (wearable devices, health apps, genetic testing services), advance care planning, communication preferences (phone, text, email, patient portal), and scheduling preferences for the annual comprehensive physical examination.
All fields are HIPAA-compliant and crafted to set the tone for a high-touch, patient-centered practice. The comprehensive pre-visit form demonstrates the thoroughness of concierge care from the first interaction, allowing patients to reflect on their health goals and priorities before meeting their physician. This detailed baseline enables the concierge physician to create a truly individualized health optimization plan, coordinate with specialists proactively, and identify risk factors for early intervention rather than reactive disease management.
What's included
- Comprehensive medical history with wellness goal setting
- Multi-generational family health history mapping
- Medication and supplement list with dosage tracking
- Lifestyle, nutrition, sleep, and stress assessment
- Appointment booking with provider and time slot selection
- Consent and membership agreement with e-signature
- Medical conditions checklist
- Structured medication list with dosage and frequency tracking
Who uses this template
- Concierge medicine and retainer-based primary care practices
- Executive health and corporate wellness screening programs
- Direct primary care and membership-based clinics
- Longevity-focused and preventive health optimization practices
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Concierge Medicine Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Concierge Medicine Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Concierge Medicine Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Concierge Medicine Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Concierge Medicine Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Concierge Medicine Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Concierge Medicine Intake Form for your practice. Set up in minutes.
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