Templates
Patient Registration Form Template: Fill Out the Intake Form Online
This is an online patient registration form that organizes basic demographics, contact details and the chief complaint into a single-page form. Patients fill it out and sign on their phone, and your clinic receives an archive-ready PDF straight away.
Fields included
- Patient Name * Text
- Date of Birth * Date
- Gender * Dropdown
- Mobile Phone * Phone
- Email Email
- Emergency Contact Name * Text
- Emergency Contact Phone * Phone
- Allergens / Reactions Long text
- Chief Complaint * Long text
- Patient / Guardian Signature * Signature
Who it is for
Built for clinics, dental, aesthetic medicine, rehab and any practice that needs a patient intake form. Replace the paper registration sheet taped to your front desk with a single QR code, so patients fill in their basic info, allergy history and chief complaint while they wait. The front desk no longer has to retype each field into the system, and every submission is saved automatically as a PDF for filing.
FAQ
Do patients need to register an account to fill out the registration form?
No. Patients just open the link or scan the QR code to fill it out and sign, with no sign-up or login required at any point. Only your clinic side needs to log in, to view and export the patient intake data you receive.
Can the completed registration form be exported?
Yes. Every submission is saved as a PDF that includes the patient's handwritten signature, ready to print or file into the medical record; you can also batch-export to Excel / CSV for list management.
Can it be changed to match our clinic's existing intake form format?
Yes. This is a template; the fields, sections and layout can all be adjusted to match your existing patient information sheet. Send us your current paper form or PDF and we'll turn it into an online version with the same layout.