A patient registration form for the front desk

Updated 2026-10-30

The front desk types the same details again and again, and a typo in a phone number costs a callback. I would rather let each new patient type their own details once. They answer on a phone, or hand the job to their AI.

How it works

  1. The patient gives a name, a birth date and the name they like to be called.
  2. They add a mobile number, an email and the way they want you to reach them.
  3. They pick a language and say if they need an interpreter.
  4. They add an emergency contact and tick that they read your privacy notice.

A short chat with the patient's AI

"What is your date of birth?" Then "What language do you prefer for appointments?" Then "Who is your emergency contact?" It shows all answers and waits for a yes. Read about agent-fillable forms.

Good to know

Insurance and ID numbers are left out on purpose. Keep those in the system your clinic already protects. Check your local privacy rules before collecting health data. This is a form, not medical advice.

Booking a child? A dental new patient form adds mouth-specific questions. A patient referral form fits when another provider sends them over. See forms for clinics for more.

Questions

Why are health questions not on this form?

Registration is the paperwork: who the patient is and how to reach them. Keeping health questions in a second form keeps this one short for the patient.

How do I handle a child registering?

The guardian field asks for a parent or guardian when the patient is under 18. Ask the parent to fill the form, and read their contact details from the phone and email columns.

Can I see who needs an interpreter?

Yes. Download the CSV and filter the needs_interpreter column, then check spoken_language. You can plan the booking before the patient arrives.

Try the form

Live demo ยท nothing is saved

Register as a new patient

Tell us who you are and how to reach you. This is the paperwork part. Health questions come later, in a separate form.

Best way to reach you
Language you prefer for appointments
I would like an interpreter
How did you hear about us?
I have read the clinic's privacy notice (required)
Use this templateAll templates

Or paste the JSON

Give this to your AI. It needs the AI Form API MCP server or an API key. It makes the form and sends you the link.

text
Create this form with the AI Form API create_form tool (or POST https://aiformapi.com/v1/forms with my API key). Then reply with the public_url.

{
  "title": "Register as a new patient",
  "description": "Tell us who you are and how to reach you. This is the paperwork part. Health questions come later, in a separate form.",
  "fields": [
    {
      "id": "legal_name",
      "label": "Name as it appears on your records",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "preferred_name",
      "label": "Name you like us to use",
      "type": "short_text",
      "max_length": 100
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "home_address",
      "label": "Home address",
      "type": "long_text",
      "max_length": 300
    },
    {
      "id": "mobile_number",
      "label": "Mobile phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "email_address",
      "label": "Email",
      "type": "email"
    },
    {
      "id": "contact_channel",
      "label": "Best way to reach you",
      "type": "single_choice",
      "options": [
        "Call",
        "Text message",
        "Email"
      ]
    },
    {
      "id": "spoken_language",
      "label": "Language you prefer for appointments",
      "type": "single_choice",
      "options": [
        "English",
        "Spanish",
        "French",
        "Mandarin",
        "Arabic",
        "Another language"
      ]
    },
    {
      "id": "needs_interpreter",
      "label": "I would like an interpreter",
      "type": "checkbox"
    },
    {
      "id": "guardian_name",
      "label": "Parent or guardian, if the patient is under 18",
      "type": "short_text",
      "max_length": 150
    },
    {
      "id": "usual_pharmacy",
      "label": "Your usual pharmacy",
      "type": "short_text",
      "max_length": 200
    },
    {
      "id": "how_found_us",
      "label": "How did you hear about us?",
      "type": "single_choice",
      "options": [
        "A friend or family member",
        "My doctor",
        "Online search",
        "A directory",
        "I walked past"
      ]
    },
    {
      "id": "emergency_contact_line",
      "label": "Emergency contact: name and phone",
      "type": "short_text",
      "required": true,
      "max_length": 250
    },
    {
      "id": "privacy_notice_read",
      "label": "I have read the clinic's privacy notice",
      "type": "checkbox",
      "required": true
    }
  ]
}

Or call the API

bash
curl -X POST https://aiformapi.com/v1/forms \
  -H "Authorization: Bearer $AIFORMAPI_KEY" \
  -H "Content-Type: application/json" \
  -d '{"title":"Register as a new patient","description":"Tell us who you are and how to reach you. This is the paperwork part. Health questions come later, in a separate form.","fields":[{"id":"legal_name","label":"Name as it appears on your records","type":"short_text","required":true,"max_length":150},{"id":"preferred_name","label":"Name you like us to use","type":"short_text","max_length":100},{"id":"birth_date","label":"Date of birth","type":"date","required":true},{"id":"home_address","label":"Home address","type":"long_text","max_length":300},{"id":"mobile_number","label":"Mobile phone","type":"phone","required":true},{"id":"email_address","label":"Email","type":"email"},{"id":"contact_channel","label":"Best way to reach you","type":"single_choice","options":["Call","Text message","Email"]},{"id":"spoken_language","label":"Language you prefer for appointments","type":"single_choice","options":["English","Spanish","French","Mandarin","Arabic","Another language"]},{"id":"needs_interpreter","label":"I would like an interpreter","type":"checkbox"},{"id":"guardian_name","label":"Parent or guardian, if the patient is under 18","type":"short_text","max_length":150},{"id":"usual_pharmacy","label":"Your usual pharmacy","type":"short_text","max_length":200},{"id":"how_found_us","label":"How did you hear about us?","type":"single_choice","options":["A friend or family member","My doctor","Online search","A directory","I walked past"]},{"id":"emergency_contact_line","label":"Emergency contact: name and phone","type":"short_text","required":true,"max_length":250},{"id":"privacy_notice_read","label":"I have read the clinic'\''s privacy notice","type":"checkbox","required":true}]}'

JSON definition

json
{
  "title": "Register as a new patient",
  "description": "Tell us who you are and how to reach you. This is the paperwork part. Health questions come later, in a separate form.",
  "fields": [
    {
      "id": "legal_name",
      "label": "Name as it appears on your records",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "preferred_name",
      "label": "Name you like us to use",
      "type": "short_text",
      "max_length": 100
    },
    {
      "id": "birth_date",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "home_address",
      "label": "Home address",
      "type": "long_text",
      "max_length": 300
    },
    {
      "id": "mobile_number",
      "label": "Mobile phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "email_address",
      "label": "Email",
      "type": "email"
    },
    {
      "id": "contact_channel",
      "label": "Best way to reach you",
      "type": "single_choice",
      "options": [
        "Call",
        "Text message",
        "Email"
      ]
    },
    {
      "id": "spoken_language",
      "label": "Language you prefer for appointments",
      "type": "single_choice",
      "options": [
        "English",
        "Spanish",
        "French",
        "Mandarin",
        "Arabic",
        "Another language"
      ]
    },
    {
      "id": "needs_interpreter",
      "label": "I would like an interpreter",
      "type": "checkbox"
    },
    {
      "id": "guardian_name",
      "label": "Parent or guardian, if the patient is under 18",
      "type": "short_text",
      "max_length": 150
    },
    {
      "id": "usual_pharmacy",
      "label": "Your usual pharmacy",
      "type": "short_text",
      "max_length": 200
    },
    {
      "id": "how_found_us",
      "label": "How did you hear about us?",
      "type": "single_choice",
      "options": [
        "A friend or family member",
        "My doctor",
        "Online search",
        "A directory",
        "I walked past"
      ]
    },
    {
      "id": "emergency_contact_line",
      "label": "Emergency contact: name and phone",
      "type": "short_text",
      "required": true,
      "max_length": 250
    },
    {
      "id": "privacy_notice_read",
      "label": "I have read the clinic's privacy notice",
      "type": "checkbox",
      "required": true
    }
  ]
}