Clinics & healthcare · 7 questions
Clinic new patient intake form template
Collect details and history before the first appointment. Free to use: sign up, choose the clinics & healthcare starter, and this form is ready to edit and send.
Clinic new patient intake form
Full name *
Date of birth *
DD / MM / YYYYEmail *
Phone *
Reason for your visit *
Type your answer…Current medications and allergies
Type your answer…Consent *
- I consent to my information being stored for my care
The questions
- 1. Full nameShort answer
- 2. Date of birthDate
- 3. EmailEmail
- 4. PhonePhone
- 5. Reason for your visitLong answer
- 6. Current medications and allergiesLong answer
- 7. ConsentMultiple choice
Add, remove or reword any question, add logic to skip the ones that don’t apply, and put your own logo and colours on it. Send it as a link, a QR code or an email.
What happens to the answers
Every response is kept, counted and passed to the right person.
Every answer in one place
Responses land in the form's table, with views and completion tracked.
The team hears straight away
Email notifications tell the right people when a new response arrives.
Follow-ups that send themselves
An automation can confirm, remind and ask again, without anyone having to remember.
Automations that come with it
The clinics & healthcare starter also sets up these follow-ups as drafts, ready to switch on.
Appointment preparation
Confirm the booking, send intake ahead of time and a reminder the day before.
Post-visit follow-up
Check in after a visit and ask how it went.
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Follow-up ·
How to close the feedback loop with customers
Close the feedback loop twice: reply to each customer, then fix the cause and tell people. Includes follow-up rules to automate and how to check a fix worked.
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Send your clinic new patient intake form today.
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