Collect new patient details, medical history, and consent before the first visit, so appointments start on time.
Ready to use
Full name
Short Answer
Date of birth
Short Answer
Phone number
Phone Number
Email address
Home address
Short Answer
Emergency contact (name and phone)
Short Answer
What brings you in? Describe your current concern.
Long Answer
Current medications and dosages
Long Answer
Allergies (medications, foods, other)
Long Answer
Significant medical history
Long Answer
Do you have insurance coverage for this visit?
Multiple Choice
I confirm the information provided is accurate to the best of my knowledge
Multiple Choice
A patient intake form that arrives complete before the first visit: contact details, emergency contact, presenting concern, medications, and allergies. All legible, structured, and done on the patient's own couch instead of a waiting-room clipboard.
Clipboard intake wastes the first fifteen minutes of every new-patient appointment and produces the least legible records in the practice. Sending this form with the appointment confirmation moves that work to home, where patients can actually check their medication names and dosages instead of guessing from memory.
The medication and allergy questions are required with explicit 'write none' guidance. The difference between a blank field and a confirmed 'none known' matters clinically. Note: for HIPAA-regulated US practices, verify your compliance requirements before collecting patient data through any general-purpose form tool; Formly is EU-hosted and GDPR compliant.
Formly is GDPR compliant and hosted in Europe, but does not currently offer HIPAA Business Associate Agreements. US practices subject to HIPAA should verify their compliance requirements before collecting patient health information through any form tool.
Data is hosted in Europe under GDPR, with no cookies or respondent tracking. You can password-protect forms, restrict workspace access, and delete submissions after transferring them to your records system.
Yes. Add specialty-specific questions (injury history for physio, dental history, etc.) in the editor, or ask Formly's AI to adapt the form to your practice.
Not an exact fit? Use this template as a starting point and edit anything, or describe what you need and let Formly's AI adapt it for you.
