Fluent Forms Template Library

Patient Intake Form Template

Take this form to investigate your patient before admission

Patient Intake Form

Patient Intake Form (#71)

Medical History 

Please complete the form. If there are questions that you would prefer not to answer or you do not know the answer then just leave them blank.

Name *

Date of Birth *

Patient's Sex *

Contact Information

Medical Information

About this template...

A patient intake form or medical intake form is a vital tool used by healthcare providers to gather a patient’s medical history, genetics, past surgeries, and current symptoms. It allows for a secure and convenient way to collect crucial information about patients. By using an online medical intake form, patients can easily provide their information from the comfort of their homes, saving time and hassle. And with Fluent Forms, healthcare providers can customize the form to their specific needs and ensure that all patient information is organized and easily accessible. Simplify your medical intake process and provide better care with our user-friendly patient intake form!

Patient Intake Form

Features of this Template

  • Collects patient medical history, past surgeries, genetics, and symptoms
  • Secure online form for easy and convenient access
  • Helps healthcare providers make informed decisions for patient care
  • Customizable fields to fit the specific needs of healthcare providers
  • Saves time and improves efficiency in the intake process.