medical intake Templates

+3 more fields

Telemedicine Consent Form

Capture patient consent for telemedicine services.

Do you have any allergies to medications?

Pre-Surgery Assessment Form

Assess readiness for surgery and collect necessary information.

Child's Full Name

Parent/Guardian Full Name

+7 more fields

Pediatric Patient Information Form

Perfect for pediatricians to collect patient information.

Patient Satisfaction Survey

Capture patient feedback with a professional survey.

Patient Demographics Form

Capture patient demographic information such as name, date of birth, gender, ethnicity, race, marital status, primary language, and signature.

New Patient Registration

Allow patients to easily register as new patients.

Medication Refill Request

Allow patients to request medication refills easily.

Primary Care Physician

+11 more fields

Medical History Form

Patient medical and health history form.

Insurance Provider

Insurance Policy Number

Group Number

+5 more fields

Insurance Information Form

I have read and understand the Notice of Privacy Practices.

Allow patients to easily provide their insurance information.

I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations.

HIPAA Privacy Acknowledgment

Capture patient acknowledgment of HIPAA privacy practices.

Follow-Up Visit Information

Have you experienced any of the following symptoms in the past 14 days?

Securely collect follow-up visit information with this professional form.

Have you been in contact with anyone diagnosed with COVID-19 in the past 14 days?

Have you traveled internationally in the last 14 days?

COVID-19 Screening Form

I have read and understand the treatment description.

COVID-19 screening form for healthcare providers.

+3 more fields

Consent for Treatment

Capture patient consent for treatment with a professional form.

Have you ever been diagnosed with a mental health condition?

+5 more fields

Behavioral Health Intake Form

Capture patient information for behavioral health assessment.

Location of Pain

Pain Intensity (0-10)

Pain Duration

Pain Assessment Form