Patient Intake Form Template

Build a customizable, HIPAA-compliant patient intake form for your practice. Select your specialty, toggle sections on or off, and print a professional form ready for new patients.

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Sunrise Family Medicine

New Patient Intake Form

2400 Westlake Drive, Suite 110, Austin, TX 78746

Tel: (512) 555-0173 | Fax: (512) 555-0174

NPI: 1234567890

Date:

MRN:

Patient Demographics

Last Name

First Name

Middle Initial

Date of Birth

Sex (M / F / X)

Preferred Pronouns

Street Address

City

State

ZIP

Phone (Home)

Phone (Cell)

Preferred Language

Race / Ethnicity (optional)

Emergency Contact

Name

Relationship

Phone

Insurance Information

Primary Insurance

Insurance Company

Plan / Group Name

Policy / Member ID

Group Number

Phone on Card

Subscriber Name

Subscriber DOB

Relationship to Patient

Secondary Insurance (if applicable)

Insurance Company

Policy / Member ID

Group Number

Please present your insurance card(s) and a valid photo ID at check-in. Copayments are due at the time of service.

Medical History

Check all conditions you have or have had:

Heart disease

High blood pressure

Diabetes

Asthma / COPD

Cancer

Stroke

Kidney disease

Liver disease

Thyroid disorder

Arthritis

Seizures / Epilepsy

Bleeding disorder

HIV / AIDS

Hepatitis

Mental health condition

Other conditions

Past Surgeries / Hospitalizations (include dates)

Allergies (medications, foods, latex, environmental)

Family History (check if any immediate family member has had):

Heart disease

Diabetes

Cancer

Stroke

High blood pressure

Mental illness

Current Medications

List all medications, vitamins, and supplements you currently take.

Medication Name	Dosage	Frequency	Prescribing Provider

No current medications

Pain Assessment

Primary pain location

Pain intensity (0 = none, 10 = worst)

When did pain begin?

How did it start? (injury, gradual, unknown)

Pain characteristics:

Sharp

Dull / aching

Burning

Throbbing

Shooting / radiating

Constant

Intermittent

Worse in morning

Worse at night

What makes it worse?

What makes it better?

Previous treatments tried

Social History

Occupation

Marital Status

Tobacco use:

Never

Former

Current

Alcohol consumption:

None

Occasional

Moderate

Heavy

Exercise frequency

Living situation (alone, family, assisted)

Consent & Acknowledgments

I consent to examination, diagnostic procedures, and treatment as recommended by my healthcare provider at Sunrise Family Medicine.

I understand that I am financially responsible for all charges not covered by my insurance. I authorize the release of medical information necessary for insurance billing.

I authorize Sunrise Family Medicine to contact me by phone, text, or email regarding appointments, test results, and health information.

I have reviewed and understand the information provided in this intake form. The information I have given is accurate and complete to the best of my knowledge.

Patient Signature

Date

Guardian / Legal Representative (if applicable)

Relationship to Patient

HIPAA Privacy Notice

Notice of Privacy Practices — Acknowledgment

Sunrise Family Medicine is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to maintain the privacy of your protected health information (PHI) and to provide you with a description of how PHI may be used and disclosed.

You have the right to: (1) request restrictions on certain uses and disclosures of your PHI; (2) receive confidential communications; (3) inspect and obtain a copy of your PHI; (4) request amendments to your PHI; (5) receive an accounting of disclosures; and (6) obtain a paper copy of this notice.

We may use and disclose your PHI for treatment, payment, and healthcare operations without your written authorization. All other uses require your written consent. You may revoke consent at any time in writing.

Reference: 45 CFR §164.520 | Privacy Officer: Dr. Sarah Chen | (512) 555-0173

I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices for Sunrise Family Medicine.

I understand that I may request a copy of this notice at any time and that I may file a complaint with the practice's Privacy Officer or with the U.S. Department of Health & Human Services if I believe my privacy rights have been violated.

Patient Signature

Date

For office use: If patient unable or unwilling to sign, document reason below and have staff member sign as witness.

Reason Not Signed

Staff Witness Signature

This form is confidential and protected under HIPAA (45 CFR Parts 160 & 164). Unauthorized disclosure is prohibited by law.

What Is a Patient Intake Form?

A patient intake form is the standard document new patients complete before their first appointment. It collects demographics, insurance details, medical history, current medications, and consent acknowledgments. Under HIPAA, intake forms must include a Notice of Privacy Practices acknowledgment so patients understand how their protected health information (PHI) will be used and disclosed.

How to Use This Template

Choose your practice type — medical, dental, therapy, or chiropractic. The builder automatically enables the most relevant sections for your specialty.
Enter practice details — your practice name, NPI, address, and privacy officer appear on the printed form header and HIPAA notice.
Toggle sections — add or remove sections like insurance, social history, or specialty-specific assessments. Use the quick presets for common configurations.
Print or copy — click Print Form for a clean, professional printout. Use Copy Text to paste into your EHR or document editor.

HIPAA Compliance Note

Every patient intake form should include a Notice of Privacy Practices acknowledgment per 45 CFR §164.520. This template includes the NPP section by default. For procedures requiring separate authorization, pair this with an informed consent form.

Intake Forms by Practice Type

Medical / Primary Care

Demographics + insurance + medical history
Current medications with dosages
Social history (tobacco, alcohol, exercise)
Family history for hereditary conditions

Dental

Dental-specific history and anxiety level
Medical crossover questions (blood thinners, diabetes)
Insurance with subscriber details
Reason for visit and chief complaint

Therapy / Mental Health

PHQ-9 depression and GAD-7 anxiety screens
Substance use and trauma history
Current and past therapy providers
Safety assessment questions

Chiropractic

Pain assessment with intensity scale
Pain characteristics and duration
Aggravating and relieving factors
Previous treatment history

Important Reminders

This template is a starting point — have your compliance officer review it before use.
Completed forms contain PHI — store them per your HIPAA policies.
42 CFR Part 2 records (substance abuse) require separate, more restrictive authorization.
State laws may require additional disclosures — check your jurisdiction.

Building a Complete Patient Onboarding Packet

A thorough new-patient packet typically pairs the intake form with a detailed medical history questionnaire, an informed consent form, and a HIPAA authorization form for releasing records to referral providers. Practices subject to the No Surprises Act should also include a good faith estimate for self-pay patients. For credentialing new providers, see our provider credentialing guide and credentialing checklist.

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