Streamline Patient Onboarding
Patient Intake Form
Collect comprehensive patient information—demographics, medical history, medications, and insurance—in one digital form that integrates with your EMR.
About This Template
New patient registration is a nightmare of paper forms, clipboard questionnaires, and manual data entry. Patients arrive 30 minutes early to fill out 15 pages of forms: demographics, medical history, medications, allergies, insurance. Front desk staff spend 20-30 minutes per patient manually transcribing information into your EMR system. Critical details get lost, insurance information is wrong, and patients feel like they're at the DMV, not a modern healthcare practice.
This template consolidates all new patient paperwork into one digital form completed before arrival. Required sections capture demographics (name, DOB, gender, contact), medical history (past conditions, surgeries, family history), current medications and allergies, insurance information, and emergency contacts. Conditional logic shows relevant fields based on selections (medication list only if taking medications). Encrypted storage (MongoDB Queryable Encryption) keeps PHI secure and HIPAA-compliant.
Reduce patient registration from 30 minutes to 5 minutes. Patients complete all paperwork before arrival, so their appointment starts on time. Data flows directly to EMR (Epic, Cerner, Athena) via HL7/FHIR integration—zero manual entry. Insurance verification happens automatically before appointment. Front desk staff process 3x more patients with the same team size.
Key Features
- Demographics collection
- Medical history
- Medication list
- Insurance information
- Emergency contacts
- HIPAA-compliant encryption (Queryable Encryption)
- PHI field protection
Use Cases
Primary Care Practice
Your primary care practice sees 50+ new patients monthly. Patients arrive 30 minutes early to fill out paper intake forms that front desk staff manually enter into EMR (Epic). Registration takes 20-30 minutes per patient, causing appointment delays. Insurance information is often wrong, requiring phone calls during appointments.
Pain point: Manual data entry takes 20-30 minutes per patient, causing appointment delays. Insurance information errors require phone calls during appointments, wasting provider time. Paper forms get lost or incomplete, requiring patients to re-fill forms.
Specialist Clinic
Your specialist clinic (cardiology, orthopedics) receives referrals requiring detailed medical history. Patients fill out paper forms that get lost or incomplete—missing critical information like past surgeries or current medications. Staff spend 30+ minutes per patient entering data into EMR, causing appointment delays.
Pain point: Incomplete medical history forms delay appointments—providers spend first 10 minutes gathering missing information. Paper forms get lost between visits, requiring patients to re-fill forms. Manual data entry causes errors (wrong medication dosages, missing allergies).
Urgent Care Center
Your urgent care center sees 100+ patients daily with walk-ins and appointments. Patients fill out paper intake forms at check-in, causing 15-20 minute wait times. Staff manually enter information into EMR while patients wait, creating bottlenecks during peak hours (evenings, weekends).
Pain point: Paper intake forms at check-in cause 15-20 minute wait times during peak hours. Manual data entry creates bottlenecks—staff can't process patients fast enough. Insurance information errors delay care—patients wait while staff verify insurance.
Telehealth Practice
Your telehealth practice provides virtual care to patients across multiple states. Patients must complete intake forms before virtual appointments, but paper forms can't be used for remote patients. You need digital intake that integrates with telehealth platform and EMR.
Pain point: Paper intake forms don't work for remote patients—can't mail forms or have patients print/fax. Manual data entry from phone calls or emails is error-prone and time-consuming. Intake delays virtual appointments—patients can't start appointment until forms are completed.
Form Fields (41)
Personal Information
First Name
Last Name
Middle Name
Date of Birth
Gender
Select gender...Marital Status
Select marital status...Social Security Number
Preferred Language
Select preferred language...Contact Information
Home Address
Home Phone
(555) 123-4567Cell Phone
(555) 123-4567Email Address
your@email.comPreferred Contact Method
Select preferred contact method...Emergency Contact
Emergency Contact Name
Relationship
Select relationship...Emergency Contact Phone
(555) 123-4567Insurance Information
Insurance Company
Policy Number
Group Number
Policy Holder Name
Policy Holder Date of Birth
Medical History
Primary Care Physician
Physician Phone
(555) 123-4567Current Medical Conditions (select all that apply)
Family History (select all that apply)
Previous Surgeries (with dates)
Previous Hospitalizations (with dates)
Allergies
Do you have any allergies?
Please list all allergies and reactions
Current Medications
List all current medications (name, dosage, frequency)
Example: Lisinopril 10mg, once dailyLifestyle
Do you smoke?
Select do you smoke?...Alcohol consumption
Select alcohol consumption...Exercise frequency
Select exercise frequency...Customization Tips
Add EMR Integration
Integrate with EMR system (Epic, Cerner, Athena) via HL7/FHIR API to automatically push patient data when form is submitted. Patient appears in EMR with all information populated—no manual entry.
Enable Insurance Verification
Integrate with insurance verification API to automatically verify coverage when insurance information is submitted. Flag patients with inactive coverage before appointment.
Add Multi-Language Support
Enable form translation for non-English speaking patients using conditional logic to show appropriate language versions based on preferredLanguage selection.
Conditional Fields by Appointment Type
Show different fields based on appointment type (specialist visits see detailed medical history, routine visits see basic information) using conditional logic.
Enable E-Signature for Consent Forms
Add signature fields for HIPAA consent, treatment consent, and financial responsibility forms to complete legally binding documentation digitally.
Integration with Patient Portal
Push patient data to patient portal so patients can update information (medications, allergies) between visits without re-filling entire form.
Suggested Workflows
Push Patient Data to EMR
Trigger: On form submissionWhen patient intake form is submitted, automatically push patient data to EMR system (Epic, Cerner, Athena) via HL7/FHIR API. Patient appears in EMR with all information populated—demographics, medical history, medications, insurance—ready for appointment.
Verify Insurance Coverage Automatically
Trigger: On form submission where insurance information is providedWhen insurance information is submitted, automatically verify coverage via insurance verification API. If coverage is inactive or invalid, immediately email patient: "Your insurance coverage could not be verified. Please contact us before your appointment."
Send Appointment Confirmation
Trigger: On form submission where appointment is scheduledAfter patient intake is completed and appointment is scheduled, automatically email patient with appointment confirmation, intake completion confirmation, and what to bring (insurance card, ID).
Notify Provider on New Patient
Trigger: On form submission where isNewPatient = trueWhen new patient intake is completed, automatically email provider with patient summary: "New patient: John Doe, 45, chief complaint: chest pain, medications: Lisinopril, allergies: Penicillin." Provider has patient information before appointment.
Developer Notes
Schema Highlights
PHI fields (SSN, medical history, medications) should use MongoDB Queryable Encryption for HIPAA compliance
Medical history stored as multi-select arrays enables efficient querying for conditions, medications, allergies
Insurance information stored as separate fields (insuranceProvider, policyNumber, groupNumber) enables validation and verification
Integration Hints
HL7/FHIR API integration with EMR systems (Epic, Cerner, Athena) to push patient data automatically
Insurance verification API integration to verify coverage when insurance information is submitted
Integration with patient portal to sync patient data for updates between visits
MongoDB Considerations
Use field-level encryption for PHI fields (SSN, medical history, medications) to meet HIPAA requirements
Index on {dateOfBirth: 1, lastName: 1} for patient lookup and duplicate detection
Index on {insuranceProvider: 1, policyNumber: 1} for insurance verification queries
Consider TTL index on incomplete intake forms (>7 days old) to trigger follow-up reminders
Tags
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Complexity
Form Type
Est. Completion
~15 min
Total Fields
41
Category
Healthcare & Wellness