23 templates

Medical and patient form templates

These templates cover the intake side of a practice: appointment requests, new-patient details, consent acknowledgements and feedback after a visit. They keep dates, contact details and yes/no answers in structured fields so staff are not retyping them.

They are general intake forms, not a certified clinical record system. If you operate under HIPAA or another regulatory framework, meeting its storage, access and retention requirements is your responsibility — the form does not handle that for you, and each template says so.

All 23 health templates

Each one is a working form. Open it, fill it in and submit it — nothing is saved — then build it in your own account with every field already configured.

Patient intake form

Insurance provider and ID as their own fields, so registering doesn't start with a phone call.

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Appointment Request Form

Collect a preferred date, time and reason for visit for clinics, salons and studios.

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Medical History

Collect a new patient's medical background before the first appointment.

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Insurance Verification

Collect insurance details before the appointment so staff can verify coverage manually.

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Dental Patient Intake

Collect a new dental patient's background, last visit date and chief complaint before their appointment.

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Telemedicine Appointment Request

Collect patient demographics and appointment preferences to schedule a virtual doctor's visit.

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Physical Therapy Referral Form

Collect referring physician details and patient information to route patients for physical therapy treatment.

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Chiropractic Intake Form

Collect new patient background, symptoms and medical history so chiropractors can plan treatment.

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Mental Health Intake Form

Collect client background and reasons for seeking therapy so counselors can prepare for the first session.

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Release of Information Form

Authorize sharing of medical records with a named recipient.

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Medical Consent Form

Patient name, procedure, checkboxes for risks explained and questions answered, typed name as record.

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Health Screening Form

Collect pre-visit temperature, symptoms and exposure history before a patient or attendee arrives.

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Personal Training Intake Form

New client collects fitness goals, experience level, medical history and availability for workouts.

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Massage Therapy Intake Form

New client name, contact info, areas of tension, pain level, and prior massage experience.

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Acupuncture Intake Form

Patient name, reason for visit, medications, pain level, and prior acupuncture experience.

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Gym Membership Application Form

Applicant name, contact info, membership type, preferred start date, and fitness goals.

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Fitness Class Registration Form

Student name, contact, class choice, session date, experience level, and any limitations.

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Yoga Class Registration Form

Student name, contact, class or style choice, session date, experience level, and health notes.

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Medical Equipment Request Form

Requester name, equipment needed, prescribing provider, delivery or pickup preference.

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Prescription Refill Request Form

Patient name, date of birth, medication name, prescription number, pharmacy, contact method.

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Patient Satisfaction Survey Form

Visit date, provider seen, satisfaction rating, and what went well or could improve.

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Dental Appointment Request Form

Request a cleaning, checkup or cosmetic appointment with preferred dates.

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Nutrition Consultation Request Form

Goals, diet restrictions and preferred format for scheduling a nutrition consultation.

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Which health template should you start from?

These differ less in their fields than in what has to be true after someone submits. That is the useful way to choose.

If someone has to be registered before they can be treated

Start from the patient intake form. Insurance provider and insurance ID are separate fields so coverage can be checked ahead of the visit, and the form stops there on purpose — a full medical history belongs on a different form, taken at a different moment.

If a first visit needs background before it starts

Start from the medical history form. Allergies and medications stay open text so a patient can describe exactly what applies to them, and date of birth is its own field so age is a calculation, not a guess from typed text.

If coverage needs checking before the visit, not during it

Start from the insurance verification form. Policy ID and group number are separate fields for staff to verify by phone — the FAQ is explicit there is no real-time eligibility API behind it.

If it's a dental visit, not a general one

Start from the dental patient form. Last-visit date and reason-for-visit are the fields the generic patient-intake-form does not need — the same vertical-specialization pattern as the restaurant-reservation-form.

If a virtual visit needs a reason before it is booked

Start from the telemedicine appointment request form. Reason for visit is a dropdown, date of birth is a date field, and an optional text field records which video platform the patient prefers. It is a general request form, not a clinical record.

If the person filling it in is the referring doctor

Start from the physical therapy referral form. It is written for the physician, not the patient: the diagnosis is required, while session count and precautions are optional. The form does not verify the physician's credentials.

If pain level should be visible before the first adjustment

Start from the chiropractic intake form. Pain is a slider, the reason for the visit is a dropdown and previous chiropractic care is a yes or no radio, so a new patient's picture is structured before they walk in.

If a therapist wants the client's own words before session one

Start from the mental health intake form. It opens with a notice that the form is not for emergencies and points to 988, then asks for an emergency contact and the client's own reason for coming rather than a self-diagnosis.

If a patient names who may see which records

Start from the release of information form. What may be shared is a checkbox group, so a patient can allow test results but not therapy notes, and an expiry date is required. It is a request form, not a legal authorisation.

If a clinic wants risks and questions confirmed separately

Start from the medical consent form. Risks explained and questions answered are two separate required checkboxes, alongside the procedure, a consent radio and a typed name. It is not a legal consent record or an e-signature.

If visitors should report how they feel before arriving

Start from the health screening form. Symptoms are a checkbox group, exposure and travel are radios, and a confirmation checkbox is required. It records what someone reports and is not a medical assessment.

If a trainer plans around goals and availability

Start from the personal training intake form. Goals are checkboxes, so a client can pick strength and mobility together, and experience and days per week are dropdowns. It is not medical clearance.

If a massage therapist wants to know new client focus areas and pain level before the first appointment

Start from the massage therapy intake form. It captures client name and contact, areas of tension via checkboxes, pain level as a 0-10 slider, and prior massage experience as a radio choice. This is a wellness intake only — the therapist makes professional judgments and performs follow-up assessment in person.

If an acupuncture practice needs initial patient information and why they are seeking treatment

Start from the acupuncture intake form. It captures patient name and phone, reason for visit as open text, current medications, pain level as a 0-10 slider, and prior experience as a radio choice. This is a general intake, not a diagnosis — the practitioner evaluates everything in person.

If a gym wants to collect membership applications with the tier chosen and start date before processing

Start from the gym membership application form. It captures applicant name and contact, membership type via dropdown (basic, premium, family, annual), preferred start date, and optional fitness goals. This is an application only — the gym handles billing, contracts, and orientation separately.

If a fitness studio wants to register students for specific classes with session time and experience level

Start from the fitness class registration form. It captures student name and email, class choice via dropdown, session date and time as separate fields, optional experience level, and any limitations. This registers interest in a seat, not a guaranteed spot — capacity and no-shows are managed outside the form.

If a yoga studio wants class sign-ups with the style chosen, session details, and any health notes

Start from the yoga class registration form. It captures student name and phone, class or style via dropdown (hatha, vinyasa, yin, power), session date and time, experience level as a radio, and optional health notes. The teacher uses experience level and health notes to offer safe modifications during class.

If a clinic or supplier wants to collect what medical equipment is being requested and how to deliver it

Start from the medical equipment request form. It captures requester name and contact, equipment needed, optional provider name, and delivery method via radio (delivery home, pickup, mail). The form records the administrative request only — the clinic or supplier verifies prescriptions and insurance separately.

If a pharmacy or clinic wants patients to request refills with medication details and pharmacy location

Start from the prescription refill request form. It captures patient name, date of birth, email and phone, medication name, optional prescription number, and pharmacy name and location. This is an administrative request only — the pharmacy verifies refills remaining and the prescription, then fills the medication.

If a clinic wants to collect visit feedback with a satisfaction score and open commentary on the experience

Start from the patient satisfaction survey form. It captures visit date, optional provider name, satisfaction as a 0-10 slider, and two optional open fields for what went well and what could improve. This is feedback collection only, not a medical record or complaint resolution system.

If a dental office needs to confirm appointments outside the form because real calendars have constraints

Start from the dental appointment request form. Collect patient name with email and optional phone, a reason for visit dropdown (cleaning, checkup, pain, cosmetic, other), and two optional date fields for preferred appointments. Add a radio for new or returning patient status. Limit: the form is a triage gate, not the booking itself — staff call back to confirm against real availability.

If a dietitian or nutritionist needs to collect intake information before the first consultation call

Start from the nutrition consultation request form. Collect name, email and optional phone, a checkbox group for goals (weight, sports, medical, wellness), an optional textarea for dietary restrictions, and a required dropdown for format (in-person, video, phone). The form requests the consultation; the consultant confirms by phone. Limit: this is an intake request, not medical advice or a personalized meal plan.

If a small business needs an intake form to collect preferred appointment date and time before a staff callback

Start from the appointment request form. It collects name, email, phone, preferred date, optional time and reason for visit. Ideal for clinics, salons and studios that review requests and schedule separately. The form does not handle emergencies or real-time booking.

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