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Registration

Patient Portal Registration Form

2 pages•12 fields•HIPAA-ready
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formisoft.com/f/patient-portal-registration
Patient Full Name
Date of Birth
Email for Portal Access
Mobile Phone Number
Preferred Username
Identity Verification (Last 4 SSN)
Communication Preferences
Appointment Reminder Method
Select...
Portal Terms of Use Agreement
I agree to the terms above
Sign here
Submit
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The Patient Portal Registration Form streamlines the process of enrolling patients in your practice's online portal. It collects the necessary identity verification details, preferred login credentials, and communication preferences to set up secure patient accounts. By digitizing this enrollment process, you increase portal adoption rates and empower patients to manage their healthcare online.

The form includes identity verification fields such as date of birth and last four digits of SSN, along with the patient's preferred email for account setup. Patients can select their communication preferences for appointment reminders, lab results, and billing notifications. A clear terms-of-use acknowledgment ensures patients understand their responsibilities for maintaining account security.

Essential for practices implementing or expanding their patient portal capabilities. Meaningful Use and MIPS requirements encourage patient portal adoption, making this form valuable for primary care offices, multi-specialty groups, and health systems focused on patient engagement and digital health transformation.

What's included

  • Patient identity verification fields
  • Email and phone for account setup
  • Communication and notification preferences
  • Consent agreement with e-signature for terms of use
  • Consent for electronic communication of health information
  • Staff verification workflow for account activation

Who uses this template

  • New patient onboarding with portal enrollment
  • Existing patient portal migration campaigns
  • Meaningful Use and MIPS compliance for patient engagement
  • Health system digital transformation initiatives

All form fields

9 fields across 2 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Email for Portal AccessEmail
Mobile Phone NumberPhone
Preferred UsernameText
Identity Verification (Last 4 SSN)Text
Communication PreferencesCheckbox
Appointment Reminder MethodDropdown
Portal Terms of Use AgreementConsent Agreement

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Sign up and start customizing the Patient Portal Registration Form for your practice. 30-day money-back guarantee.

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$79.99/mo · Cancel anytime · HIPAA compliant

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