New Patient Registration template

A one-time registration form that sets up a patient record: contact details, date of birth, home address, insurance, an emergency contact, and the preferred pharmacy for prescriptions. It uses a single-page layout, so patients see the whole form at once and can fill it in any order — closer to the paper form they expect, minus the clipboard.

Use this template Start free — no card

7 questions · Free plan: 500 responses/month · fully customizable

Interactive — fill it in like a respondent would.Open full width

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Your contact detailsContact info

02Date of birthDate

03Home addressAddress

04Insurance provider and member IDShort text

05Emergency contact (name and phone number)Short text

06Preferred pharmacy (name and location)Short text

07How did you hear about us?Dropdown

When to use this template

A practice onboarding new patients by email before their first visit, so the front desk starts from a complete record
A pediatric office registering families, where the emergency-contact line matters more than in most specialties
A clinic that keeps losing prescriptions to the wrong pharmacy and wants the preferred pharmacy captured at registration
A practice tracking growth channels with the "how did you hear about us" dropdown — referrals, insurance directory, or search

Tips to get more from it

The insurance field's helper text says to leave it blank for out-of-pocket patients — a lighter-touch alternative to the skip-rule approach the Patient Intake template uses
Emergency contact is required and pharmacy is optional; review those toggles against your practice's policy before publishing
The referral-source dropdown quietly doubles as marketing data — its answers export to CSV alongside the registration, so you can count which channels bring in new patients

Questions people ask

What's the difference between patient registration and patient intake forms?

Registration creates the record once — demographics, insurance, emergency contact, pharmacy. Intake is per-visit information like the reason for the appointment. Zunoform has a separate Patient Intake template for the latter.

Can I brand this form with my practice's logo?

You can customize the form's look on any plan; removing Zunoform's own branding from published forms requires the Pro plan at $14.99/mo.

How do I get registrations into my practice management system?

Responses export as CSV with one row per patient and each field in its own column, which most practice management systems can import or staff can key in from.