Patient Intake template

A patient intake form template that collects contact details, date of birth, home address, visit reason, and insurance information before the patient arrives. Its one piece of logic earns its keep: patients who select self-pay skip the insurance-details question entirely, so nobody types "N/A" into a member ID box.

Use this template Start free — no card

9 questions · works on the free plan (500 responses/month) · fully customizable

1 built-in logic rule

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

04What brings you in?Dropdown

05Will you be using insurance?Multiple choice

06Insurance provider and member IDShort text

07Anything you'd like your care team to know beforehand?Long text

When to use this template

A family practice emailing the intake link with appointment confirmations so front-desk check-in takes two minutes instead of ten
A physical therapy clinic that needs the visit reason ahead of time to book the right room and equipment
A direct-primary-care practice with many self-pay patients, who take the shorter path the skip rule creates
A small clinic replacing the clipboard-and-photocopied-sheet routine with something patients complete at home

Tips to get more from it

The insurance question drives the skip rule — self-pay patients never see the provider-and-member-ID field. If you add more insurance questions, attach them to the same rule
The "what brings you in" dropdown keeps visit reasons to six tidy categories; the open text box after it is where patients add detail, so resist growing the dropdown
The ending reminds patients to bring photo ID. Edit that closing text to include your parking or arrival instructions — it's the last thing patients read

Questions people ask

Can patients fill out intake forms before their appointment?

Yes — that's the point of this template. Send the form link in your confirmation email and the completed intake arrives in your Zunoform responses before the visit.

Can I customize the intake questions for my practice?

Every question is editable. Change the visit-reason options, add fields your practice needs, or remove ones you don't — the skip rule for self-pay patients can be adjusted in the same editor.