Patient Intake Form

Purpose: This form is used to collect essential patient data for new individuals receiving care. It includes personal contact details, emergency contacts, medical history, current medications, allergies, and insurance information.

Patient Information

Full Name: {fullName}

Date of Birth: {dateOfBirth}

Gender: {gender}

Phone Number: {phone}

Email Address: {email}

Address: {address}

Emergency Contact

Contact Name: {emergencyContactName}

Relationship to Patient: {emergencyRelationship}

Phone Number: {emergencyPhone}

Insurance Information

{#hasInsurance}

Insurance Provider: {insuranceProvider}

Policy Number: {policyNumber}

Group Number: {groupNumber}

{/hasInsurance}

{^hasInsurance}

No insurance information provided.

{/hasInsurance}

Medical History

Please check all that apply:

{#medicalConditions}

• {conditionName}

{/medicalConditions}

Current Medications

{#currentMedications}

• {medicationName}: {dosage}, {frequency}

{/currentMedications}

Allergies

{#allergies}

• {allergy}

{/allergies}

Primary Care Physician

Doctor’s Name: {doctorName}

Phone Number: {doctorPhone}

Clinic Name: {clinicName}

Consent and Signature

I, {fullName}, confirm that the above information is accurate to the best of my knowledge and consent to treatment according to clinic policies.

Signature: ______________________

Date: {signatureDate}