Your Practice Name
New Patient Intake Form
For patient completion
Please print clearly
Please print clearly and complete each section that applies to you. Ask our staff if you need assistance.
1 · Patient details
Legal first name
Legal last name
Preferred name
Date of birth
Pronouns (optional)
Patient ID / MRN (office use)
Responsible party, if applicable
Relationship
2 · Contact information
Street address
City
State
ZIP code
Mobile phone
Other phone
Email address
Preferred contact
CallTextEmail
3 · Emergency contact
Contact name
Relationship
Phone
4 · Insurance information
Primary insurance / payer
Member ID
Group number
Subscriber name
Subscriber date of birth
Relationship to patient
Secondary insurance / payer (if any)
Secondary member ID
Secondary group number
5 · Visit information
What is the main reason for today's visit?
Referring provider (if applicable)
Preferred pharmacy
Pharmacy phone
Pharmacy city / location
6 · Health history
Current or past medical conditions
Prior surgeries or hospitalizations, including approximate dates
Relevant family medical history
7 · Medications and allergies
Current medications, vitamins, and supplements
| Name | Dose | How often | Reason |
|---|---|---|---|
Medication or food allergies
Reaction(s)
No known medication allergiesNo known food allergies
8 · Communication and access needs
Preferred spoken language
Preferred written language
Interpreter, accessibility, sensory, mobility, or other support needs
Appointment messages
Voicemail okayText okayEmail okay
9 · Patient or guardian confirmation
I confirm that the information I provided on this form is accurate and complete to the best of my knowledge. I understand that I should tell the practice when this information changes.
Patient / guardian signature
Date
Printed name
Relationship, if guardian