Patient Intake Form
Blank template for clinical practices – Free download from intake.icu
Practice name / logo: ________________________________    Date: ______________

1. Patient demographics
Legal last name: ________________    Legal first name: ________________
Middle name / initial: ______________    Preferred name: ________________
Date of birth (MM/DD/YYYY): ______________    Sex / gender identity: ______________
Street address: ________________________________________________
City: ________________    State: ______    ZIP / postal code: ______________
Primary phone: ________________    Email: ________________
Preferred contact method: ________________    Preferred language: ________________
[ ] I consent to receive appointment reminders by phone / text / email (circle applicable)

2. Insurance / subscriber information
Primary insurance (or write self-pay):
Insurance plan / payer name: ________________    Member / subscriber ID: ________________
Group number: ________________    Plan type (HMO / PPO / other): ________________
Subscriber name (if not patient): ________________    Subscriber DOB: ________________
Patient relationship to subscriber: ________________    Insurance phone: ________________
Secondary insurance (if any):
Secondary payer name: ________________    Secondary member ID: ________________
Secondary group number: ________________    Relationship to subscriber: ________________

3. Reason for visit
Today's chief concern / reason: ________________________________________________
How long has this been present?: ________________
Referring clinician (if any): ________________
Additional details:
________________________________________________________________
________________________________________________________________

4. Medical & medication history
Significant past medical conditions, surgeries, hospitalisations:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Current medications (name, dose, frequency — include OTC and supplements):
________________________________________________________________
________________________________________________________________
________________________________________________________________

5. Allergies
Medication allergies (or none known): ________________    Reaction: ________________
Other allergies (food, latex, etc.): ________________    Reaction: ________________

6. Preferred pharmacy
Pharmacy name: ________________    Pharmacy phone: ________________
Pharmacy address / cross-streets: ________________________________________________
Mail-order pharmacy (if any): ________________

7. Emergency contact
Contact full name: ________________    Relationship: ________________
Primary phone: ________________    Alternate phone: ________________

8. HIPAA Notice of Privacy Practices — acknowledgment of receipt
Covered providers must make a good-faith effort to obtain written acknowledgment of receipt of the NPP (45 CFR 164.520(c)(2)). Confirm exact language with your privacy officer.
I acknowledge that I have received (or been offered) a copy of this practice's Notice of Privacy Practices.
Patient / authorised representative signature: ________________    Date: ______________
If representative: print name and relationship: ________________________________________________
[ ] Patient declined to sign — staff reason: ________________________________________________

9. Consent to treat
Consent-to-treat language is practice- and state-specific. Replace this placeholder with language your compliance team has approved.
I consent to evaluation and treatment by the clinicians of this practice for the conditions presented. I understand that I may ask questions and may refuse any recommended service.
Patient / authorised representative signature: ________________    Date: ______________
If representative: print name and relationship: ________________________________________________

10. Financial responsibility / assignment of benefits
Confirm wording with your billing lead. This line is not a Medicare Advance Beneficiary Notice (ABN).
I understand I am financially responsible for charges not paid by insurance (including deductibles, coinsurance, copayments, and non-covered services). I authorise this practice to bill my insurer and to receive payment of benefits on my behalf for services rendered.
Patient / authorised representative signature: ________________    Date: ______________

Template only – confirm HIPAA acknowledgment and consent language with your compliance team. Generated by intake.icu.
This is a blank starting form, not legal advice and not a determination that any completed document is valid. No patient data is collected by intake.icu when you download or print this file.