Patient intake form for a smoother first visit

Updated 2026-10-30

Waiting rooms are a bad place to fill in a clipboard. I would rather send new patients one link before they arrive. They answer at home, with their medicine list in reach.

Who it is for

Small clinics, dentists, physios and independent practitioners who want the basics in hand before the appointment starts.

What each question is for

  • Name, date of birth, phone: so you match the right person to the right slot.
  • What brings you in: the first thing a practitioner reads.
  • Medicines and allergies: the two answers people forget at the desk.
  • Previous provider: helps you ask for old records.
  • Emergency contact: needed on day one, rarely remembered.
  • Confirmation box: the patient says the details are right.

What a patient's AI would ask

"What is your date of birth?" Then "What medicines do you take?" Then "Who should we call in an emergency?" It lists the answers and waits for a yes. See agent-fillable forms.

Before you use it

Check your local privacy rules before collecting health data. This is a form, not medical advice. More ideas are in forms for clinics. Pair it with a medical history form or the general client intake template, and think about a patient feedback survey afterwards.

Questions

Does this replace my clinic software?

No. It collects answers and gives you rows as JSON or CSV. You copy what you need into your own record system.

Can a patient fill it on a phone?

Yes. The public form works on a phone. A patient can also hand it to their own AI agent, which asks for what it does not know.

Should I ask for insurance details here?

This template leaves them out on purpose. Add only the fields you need, and keep sensitive numbers in the system your clinic already protects.

Try the form

Live demo ยท nothing is saved

New patient intake

Please fill this in before your first visit. It helps us make the most of your appointment.

How should we reach you?

Include vitamins and supplements. Write none if there are none.

I confirm these details are correct to the best of my knowledge (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": "New patient intake",
  "description": "Please fill this in before your first visit. It helps us make the most of your appointment.",
  "fields": [
    {
      "id": "full_name",
      "label": "Full legal name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "date_of_birth",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "phone",
      "label": "Phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "email",
      "label": "Email",
      "type": "email"
    },
    {
      "id": "contact_preference",
      "label": "How should we reach you?",
      "type": "single_choice",
      "options": [
        "Phone call",
        "Text message",
        "Email"
      ]
    },
    {
      "id": "reason_for_visit",
      "label": "What brings you in?",
      "type": "long_text",
      "required": true,
      "max_length": 1500
    },
    {
      "id": "current_medicines",
      "label": "Medicines you take now",
      "type": "long_text",
      "help": "Include vitamins and supplements. Write none if there are none.",
      "max_length": 1500
    },
    {
      "id": "allergies",
      "label": "Allergies",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "previous_provider",
      "label": "Your previous doctor or clinic",
      "type": "short_text",
      "max_length": 200
    },
    {
      "id": "emergency_contact_name",
      "label": "Emergency contact name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "emergency_contact_phone",
      "label": "Emergency contact phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "details_correct",
      "label": "I confirm these details are correct to the best of my knowledge",
      "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":"New patient intake","description":"Please fill this in before your first visit. It helps us make the most of your appointment.","fields":[{"id":"full_name","label":"Full legal name","type":"short_text","required":true,"max_length":150},{"id":"date_of_birth","label":"Date of birth","type":"date","required":true},{"id":"phone","label":"Phone","type":"phone","required":true},{"id":"email","label":"Email","type":"email"},{"id":"contact_preference","label":"How should we reach you?","type":"single_choice","options":["Phone call","Text message","Email"]},{"id":"reason_for_visit","label":"What brings you in?","type":"long_text","required":true,"max_length":1500},{"id":"current_medicines","label":"Medicines you take now","type":"long_text","help":"Include vitamins and supplements. Write none if there are none.","max_length":1500},{"id":"allergies","label":"Allergies","type":"long_text","max_length":1000},{"id":"previous_provider","label":"Your previous doctor or clinic","type":"short_text","max_length":200},{"id":"emergency_contact_name","label":"Emergency contact name","type":"short_text","required":true,"max_length":150},{"id":"emergency_contact_phone","label":"Emergency contact phone","type":"phone","required":true},{"id":"details_correct","label":"I confirm these details are correct to the best of my knowledge","type":"checkbox","required":true}]}'

JSON definition

json
{
  "title": "New patient intake",
  "description": "Please fill this in before your first visit. It helps us make the most of your appointment.",
  "fields": [
    {
      "id": "full_name",
      "label": "Full legal name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "date_of_birth",
      "label": "Date of birth",
      "type": "date",
      "required": true
    },
    {
      "id": "phone",
      "label": "Phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "email",
      "label": "Email",
      "type": "email"
    },
    {
      "id": "contact_preference",
      "label": "How should we reach you?",
      "type": "single_choice",
      "options": [
        "Phone call",
        "Text message",
        "Email"
      ]
    },
    {
      "id": "reason_for_visit",
      "label": "What brings you in?",
      "type": "long_text",
      "required": true,
      "max_length": 1500
    },
    {
      "id": "current_medicines",
      "label": "Medicines you take now",
      "type": "long_text",
      "help": "Include vitamins and supplements. Write none if there are none.",
      "max_length": 1500
    },
    {
      "id": "allergies",
      "label": "Allergies",
      "type": "long_text",
      "max_length": 1000
    },
    {
      "id": "previous_provider",
      "label": "Your previous doctor or clinic",
      "type": "short_text",
      "max_length": 200
    },
    {
      "id": "emergency_contact_name",
      "label": "Emergency contact name",
      "type": "short_text",
      "required": true,
      "max_length": 150
    },
    {
      "id": "emergency_contact_phone",
      "label": "Emergency contact phone",
      "type": "phone",
      "required": true
    },
    {
      "id": "details_correct",
      "label": "I confirm these details are correct to the best of my knowledge",
      "type": "checkbox",
      "required": true
    }
  ]
}