New Patient Intake Form
A new-patient intake capturing contact details, reason for visit, and general health notes.
- Reason for visit
- General health notes
- Responsive
- No dependencies
Fields included
- Name
- Phone
- Reason for visit
- Notes
Works great with
How to Use This Template
- 1Sign up for a free Static Forms account to get your API key.
- 2Copy the HTML code above and save it as an
.htmlfile. - 3Replace
YOUR_API_KEYwith your actual API key. - 4Deploy the file to your website and start receiving submissions in your inbox.
Frequently asked questions
Is this patient intake form HIPAA compliant?
No. This is a general intake template, not a HIPAA-compliant or medical-grade system. Do not use it to collect or transmit protected health information (PHI) you are legally required to safeguard. Use a compliant platform for PHI.
What can I safely collect with this form?
Use it for basic contact details, the reason for a first visit, and scheduling notes. Gather clinical and sensitive medical history through a compliant system instead.
How do I confirm a new patient appointment?
Set up an autoresponder to acknowledge the intake, then confirm a time by reply or with the appointment booking template.
Can I customise the reason-for-visit options?
Yes. Edit the select options to match the services your practice offers so intakes arrive pre-categorised.
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Start receiving form submissions today
No backend code needed. Sign up, grab your API key, and you are ready to go.