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HealthcareMulti-step

Patient Intake Form Template

Structure a new-patient intake — personal details, insurance and medical history — across three clear steps, collected before the visit. Share the link, embed it, or pull responses via API.

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12 fields Multi-step Free on every plan

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What's Inside

Twelve Fields, Three Steps

A standard intake structure you can shape to your practice. Edit, reorder, or remove any field in the builder.

01First Name *text
02Last Name *text
03Date of Birth *date
04Email Address *email
05Phone Number *phone
06Home Address *long text
07Insurance Providertext
08Insurance IDtext
09Known Allergieslong text
10Current Medicationslong text
11Existing Medical Conditionslong text
12Reason for Visit *long text
1

Personal Information

Name, date of birth, and contact details.

2

Insurance

Provider and member ID, if you collect them.

3

Medical History

Allergies, medications, conditions, and the reason for the visit.

One Definition, Three Channels

Ship the Same Form Three Ways

Use as a page

A hosted, shareable form page — drop the link anywhere you need it.

GET forms.expert/h/patient-intake

Embed as a widget

A one-line script that auto-resizes inside your own page — no iframe wrangling.

<script src="…/e/patient-intake">

Call via API

Post submissions straight into your systems with a REST endpoint and signed webhooks.

POST /f/{id}/patient-intake
How to Use It

Live in Three Steps

  1. 1

    Start from this template

    It opens in the builder pre-filled, free on every plan, no credit card.

  2. 2

    Make it yours

    Adjust the insurance and history fields, add questions, and restyle it to match your practice.

  3. 3

    Publish & collect

    Share the hosted link before a visit, or embed it — and pair it with other registration forms.

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FAQ

Patient Intake Questions

Yes, browsing and using it is free on every plan, with no credit card required.

Start Intake Before the Visit, Free

Open it, fill in the live preview, and ship it as a page, a widget, and an API.

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Free on every plan · no credit card required