Patient Intake
A new-patient intake form for clinics and practices.
Overview
The Patient Intake template lets clinics and private practices gather new-patient information online before the first appointment. Patients provide their demographics and contact details, describe the reason for their visit, and share insurance or GP information. Completing the form in advance saves time at reception, reduces queues, and means clinicians arrive at the appointment already understanding why the patient has come in.
Tailor the form in the NodumForms drag-and-drop builder to suit your practice. Use short text fields for name, date of birth and address, email and phone fields for contact details, a long text field for the reason for the visit, and dropdowns for preferred clinic or appointment type. Add fields for insurance provider, policy number and the patient's GP, and use a file upload if you need a referral letter or ID document. Apply your practice branding through the Styles panel so the form looks reassuring and professional to a new patient.
Patient details are handled with care: connections use TLS encryption, IP addresses are stored hashed, and NodumForms does not train on your data. Please note this is a secure intake form rather than a medical records or EHR system, and it is not certified as HIPAA compliant, so do confirm the arrangement meets your own regulatory and data-protection requirements before going live. Share the form by link in appointment confirmation emails, or embed it directly on your practice website so patients can complete it at home. Review submissions in the dashboard, and delete a response once the details have been recorded in your own practice system.
Perfect for
Register new patients before they arrive
Clinic receptionists and practice managers use this form to collect new-patient details ahead of the first visit. When a patient books, the practice emails the intake link, and the patient fills in their demographics, reason for visit and insurance details from home. By appointment time, reception has the paperwork ready and the clinician knows what to expect, so the visit starts smoothly.
Why this template works
- Save reception time by collecting details before the appointment
- Capture demographics, reason for visit and insurance in one form
- Protect patient data with TLS encryption and hashed IP addresses
- Delete responses once recorded to keep your dashboard tidy
How to use
- Select the Patient Intake template to load the form into your builder.
- Customise the fields for your practice and apply your clinic branding.
- Publish the form and add the link to confirmation emails, or embed it on your website.
- Review submissions in the dashboard and delete responses once recorded in your practice system.
What this template includes
- Full name
- Date of birth
- Contact email and phone
- Reason for visit
- Insurance provider and policy number
- GP or referring doctor
- Referral letter upload
FAQ
- Is the patient intake form HIPAA compliant?
- This is a secure intake form, not a certified HIPAA or EHR system. Submissions use TLS encryption and hashed IP addresses, but you should confirm the arrangement meets your own regulatory and data-protection requirements before use.
- Can I add insurance and GP fields?
- Yes. The drag-and-drop builder lets you add fields for insurance provider, policy number and the patient's GP, plus a file upload for referral letters or ID, so you capture everything your practice needs.
- How do patients receive the form?
- Publish the form for a shareable link you can include in booking confirmation emails, or embed it on your practice website so new patients can complete their details before they visit.