Free patient intake form template (general and pediatric)

What belongs on a patient intake form

An intake form is a data-collection decision, and over-collection has real costs: longer forms get abandoned or half-completed, and every field you collect is information you now hold and must protect. The template includes what downstream workflows actually consume, and nothing else.

Identity and contact: legal name, date of birth, address, phone, email, and preferred contact method. Payer details: insurer, member ID, group number, subscriber name and relationship, in the structure billing reads, because a transposed member ID surfaces weeks later as a rejected claim. History: current concerns, relevant conditions, medications and allergies, scoped to what the treating clinician needs at a first visit. Consents and policies: consent to treat, privacy acknowledgment, financial policy and cancellation policy, each with its own signature line, since a single signature covering all four is far weaker if any one of them is ever disputed.

The pediatric version adds guardian identity and relationship, household and custody notes where relevant, school information, and guardian signatures throughout: the patient is the child; the paperwork belongs to the adult.

Download the patient intake form (CSV)

The download is the field list itself, one label per line with a blank beside it, grouped into patient, responsible adult, emergency contact, primary and secondary coverage, referral and clinical intake. Lay it out on your own letterhead, or use it as the checklist for building a digital form.

What does not belong on an intake form

Social security numbers (payers stopped needing them; do not hold them), full financial details beyond the card used to pay, and clinical deep-dives that belong in the clinician’s assessment conversation. If a field’s answer never changes a workflow, delete the field.

Ending the retyping step

A paper or PDF form ends its life being retyped into the practice management system, and that transcription is where member IDs transpose and names lose their spelling.

In MegAligna, intake goes to the patient or guardian as a link before the first visit, and the answers land as structured chart fields: demographics as demographics, payer details in the shape billing reads, and consents as signed, versioned documents.

Collecting this on paper and typing it in afterwards is the failure this template cannot fix. Patient intake software writes the same fields straight into the chart, including the release and assignment consents that Boxes 12 and 13 of the CMS-1500 depend on.