Patient intake form template
A free patient intake form template for the administrative half of intake: consent first, then contact details, the type of visit, how someone expects to pay, one emergency contact and your cancellation policy. Three logic rules come wired in, and every clinical question is left out on purpose.
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Read this first
Not for protected health information
This template is built for practices outside HIPAA scope: coaches, wellness practitioners, and therapists, physical therapists and clinics outside the US working to GDPR or local rules. Check what applies where you practice before you publish. The full stance is on our page about patient intake forms for small practices, and how we handle respondent data is on the security page. We make form software; we are not your compliance advisor.
14
Steps, all editable
3
Logic rules pre-built
0
Clinical questions, by design
$0
To clone, publish and collect
What's inside
Fourteen steps, none of them clinical
One question per screen, answered on a phone the evening before. Here is question 8, which asks how someone will pay without asking for a policy number.
8 →
How do you expect to pay for your sessions?
Just the method for now. We don't need an insurer or a policy number.
Every screen carries your logo, colors and font. See how conversational forms behave on a phone.
The full step list
Before you start
StatementAre you happy for us to keep these details to arrange your appointments?
Yes/NoWhat is this visit for?
Single ChoiceWhat's your full name?
Full NameWhat's the best email to reach you on?
EmailWhat's the best number to reach you on?
Phone NumberWhat's your date of birth?
Date, optionalHow do you expect to pay for your sessions?
Single ChoiceHow did you hear about us?
DropdownWho should we contact in an emergency?
Short TextWhat's their phone number?
Phone NumberOur cancellation policy
StatementDo you agree to the cancellation policy?
Yes/NoThanks. We'll confirm your appointment within one working day.
Thank You
One more step ships hidden: the insurance reminder in rule 3 below. Delete any step, add another question type, or drag the order around.
Before you publish
How to write a patient intake form that asks for less
Every field on an intake form is something you then have to store, protect, explain and eventually delete. A good patient intake form collects what the front desk needs this week and leaves the rest to the appointment.
Ask for consent before any personal detail
Question 2 asks whether the person is happy for you to keep their details, before a single name or email is typed. The order matters. If someone answers No, a logic rule ends the form on the spot, and the response holds that No and no personal details. Put consent at the end instead and you would already hold their name, phone number and date of birth by the time they decline. The Statement before it says why you ask, who reads the answers and how long you keep them.
Ask what the visit is for, not why
A reason for the visit, written out in someone's own words, is a presenting complaint, and that is health information in almost every jurisdiction. Question 3 asks for the type of visit instead: a first appointment, a follow-up, a free intro call or a general question. That tells you how long to book and who should see them. The clinical story belongs in the consultation.
Date of birth only if you use it
Plenty of practices ask for a date of birth out of habit. Keep question 7 if you need to confirm someone is an adult before booking, or to tell two clients with the same name apart. Otherwise delete it. A field you never use is still data you have to protect.
Payment method, never policy numbers
Question 8 asks how someone expects to pay: self-pay, through insurance, or not sure yet. It never asks for an insurer, a member number or a policy number. Anyone who picks insurance sees one extra Statement asking them to bring their card to the first visit, where you check coverage in person. Upform does not take payments either, so fees are settled however you settle them today.
Keep the emergency contact to two fields
A name, a relationship and a phone number are all the front desk needs. Question 10 takes the name and relationship on one Short Text line, and question 11 takes their number. Resist adding their address or email. You are holding a third person's details, and they never filled in your form.
Delete what you no longer need
Book the appointment, move what you must keep into the system that holds your client records, and once a response has done its job, delete it. A form builder makes a good front door and a poor filing cabinet. Our guide to GDPR-compliant forms covers consent wording and retention.
By design
What's in, and what's left out on purpose
Before adding a question, check which list it belongs on.
In the template
- Consent to keep details, asked before anything personal.
- Name, email and phone, so you can confirm the booking.
- Visit type as a choice, never as free text.
- Date of birth, optional, and only if you use it.
- Payment method: self-pay, insurance or not sure yet.
- How they heard about you, as a short Dropdown.
- One emergency contact: a name, a relationship and a number.
- Your cancellation policy, then a Yes/No agreeing to it.
Left out on purpose
- Symptoms, or a reason for the visit in the person's own words
- Medical history, diagnoses, medication and allergies
- Mental health, risk or screening questions
- Insurer names, member or policy numbers, and claims detail
- Uploads of ID documents, insurance cards or referral letters
- Social security, national insurance or health service numbers
Upform routes, it does not calculate. There is no scoring engine, so a screening questionnaire that adds up points is out of scope.
Already wired in
The logic that ships with the template
Three rules ship switched on, in the same Logic panel every form uses: a flat list of AND/OR conditions, 20 operators and four actions (show, hide, jump and end form).
Conditional Logic
3 rules configured
Rule Summary
When Consent is exactly "No" → End form
Rule 1: no consent, no personal data
If someone answers No at question 2, the form ends there. The response holds that one No and no personal details.
Rule 2: a shorter path for quick questions
Pick Free intro call or General question at question 3 and the date of birth and both emergency contact steps disappear.
Rule 3: a reminder for insured clients
Pick Through my insurance at question 8 and a hidden Statement appears, asking them to bring their card to the first visit.
Edit or switch off any rule in the Logic panel. The full set of operators is on the conditional logic page.
After the submit
Where the intakes land
Every submission lands in your responses table with search, a date filter and CSV export. Send it onward only where you need it: each integration is one more place the data lives.
Google SheetsAppends each intake as a row
NotionA row in a database you choose to share
WebhooksPosts each response to your own endpointSheets and Notion connect through your own account. If you connect Slack, point it at a private channel only the front desk can see. Every destination is on the integrations page.
Related templates
Four more forms from the same free library, all clonable in one click.
What do you need help with?
Client intake form
When intake looks more like onboarding.
Onboarding · ServicesWhen could you come in?
Booking form
Earliest date and preferred slots for repeat visits.
Events · ServiceHow can we help?
Contact form
The short version for your contact page.
Lead generationHow was your first visit?
Customer feedback form
Ask how the first visit went.
FeedbackFrequently asked questions
Is this patient intake form template free?
Yes, and it stays free. Cloning the template, publishing it and collecting intakes all sit on the Upform free plan, which caps neither forms nor responses. Your published form carries a small Upform mark; Pro is $12 a month and removes it, lifts the file storage limit and adds up to five team members.
Is this patient intake form HIPAA compliant?
No. Upform does not sign a Business Associate Agreement and holds no healthcare certification. If you handle protected health information under US HIPAA rules, use a HIPAA-eligible form provider that will sign a BAA with you. This template is for the non-clinical side of intake at practices outside HIPAA scope.
Why doesn't the template ask about medical history?
Because a general form builder is the wrong place for it. Symptoms, diagnoses, medication and treatment history are health data almost everywhere, with extra rules on consent, storage and sharing. Collect the administrative minimum here and take the clinical history in the appointment, or in the system that already holds your records.
Does the template ask for insurance details?
Only the payment method: self-pay, through insurance or not sure yet. It never asks for an insurer, a member number or a policy number. If you are a HIPAA covered entity, keep insurance detail out of Upform entirely.
Can patients sign the intake form online?
Upform has no signature field. Consent and policy agreement are a Statement step followed by a Yes/No, recorded with the date and time of the response. If your rules require a legally executed signature, send that one document through an e-signature tool.
Get started
Take intake off the clipboard
Clone the patient intake form template, cut it to the questions your practice actually uses, publish the link. About ten minutes.
Upform is not HIPAA compliant and does not sign a BAA. Keep protected health information in a vendor that will.