formisoft

Self-Pay Patient Registration Form

Asks about full legal name, home address, and reason for visit. Built for direct primary care and concierge medicine patient registration.

Questions
10
Page
1
Time
about 3 min

Includes

  • E-signature
  • Consent agreement
  • Emergency contact
  • Card payment
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Your practice

Self-Pay Patient Registration Form

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Emergency Contact

Live preview. Tap through it like a patient.

Who it is for

  • Direct primary care and concierge medicine patient registration
  • Urgent care and walk-in clinics serving uninsured patients
  • Dental and cosmetic practices with transparent cash-pay pricing
  • Practices offering sliding scale or charity care programs

Formisoft for DentalFormisoft for Med Spas

What's inside

  1. Full Legal NameText
  2. Date of BirthDate
  3. Phone NumberPhone
  4. Email AddressEmail
  5. Home AddressText
  6. Reason for VisitLong Text
  7. Online PaymentPayment
  8. Emergency ContactEmergency Contact
  9. Information acknowledgmentConsent Agreement
  10. Patient SignatureE-Signature

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Self-Pay Patient Registration Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

Related templates

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Questions

Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.

Yes. You can add, remove, reorder, or reword any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Patients open a secure link from an email, a text, or a QR code and complete the form on their phone, tablet, or computer before their appointment. No app download required.

Yes, on Front Desk. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Yes. The Self-Pay Patient Registration Form works on any device. Most patients complete intake forms on their phone, so every template is built for small screens first.

Send it before the visit, so patients arrive ready.

Add the Self-Pay Patient Registration Form to your account and make it yours in a few minutes.

Cancel anytime · BAA included

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