Form template · Doctor appointment
A patient intake form collects a new patient's details before the first visit. This free HTML template has 23 fields in five sections — patient, emergency contact, insurance, care team, consent — and posts to one splitforms endpoint.
This template is one of our free HTML form templates. See more form templates by industry.
Overview
A patient intake form is what a new patient fills out before the first appointment so the front desk isn't re-keying a clipboard at check-in. The free HTML template on this page has 23 fields in five sections: patient details (name, date of birth, contact, address), emergency contact, insurance or self-pay, care team (primary care physician, preferred pharmacy), and two required consent checkboxes. It is a plain form that posts to one splitforms endpoint with a hidden access key, so it drops into a WordPress, Squarespace, or static practice site with no server behind it. Each intake is saved to your dashboard and emailed to the front desk on every plan, and the first 500 submissions are free in total. It deliberately skips medical history, medications, and allergies: splitforms is not HIPAA compliant and signs no BAA, so keep clinical questions in a portal that does.
Every template is free and fully editable in the drag-drop builder — swap fields, colors, and the button label before you publish.
No server, API route, or SDK — your Patient Intake Form posts straight to one endpoint.
Every submission is emailed to you and saved to a searchable dashboard — spam filtered before it reaches you.
It's plain HTML you own — paste the Patient Intake Form snippet, swap in your access key, and ship.
Copy and ship
Plain HTML that posts to the /api/submit endpoint. Replace YOUR_ACCESS_KEY with the key from your dashboard; that's the only edit.
<form action="https://splitforms.com/api/submit" method="POST">
<input type="hidden" name="access_key" value="YOUR_ACCESS_KEY">
<input type="hidden" name="subject" value="New patient intake">
<fieldset>
<legend>1. Patient details</legend>
<label>First name <input type="text" name="first_name" autocomplete="given-name" required></label>
<label>Last name <input type="text" name="last_name" autocomplete="family-name" required></label>
<label>Date of birth <input type="date" name="date_of_birth" autocomplete="bday" required></label>
<label>Email <input type="email" name="email" autocomplete="email" required></label>
<label>Mobile phone <input type="tel" name="phone" autocomplete="tel" required></label>
<label>Street address <input type="text" name="address" autocomplete="street-address" required></label>
<label>City <input type="text" name="city" autocomplete="address-level2" required></label>
<label>State / province <input type="text" name="region" autocomplete="address-level1" required></label>
<label>ZIP / postal code <input type="text" name="postal_code" autocomplete="postal-code" required></label>
<label>Best way to reach you
<select name="preferred_contact">
<option>Text message</option>
<option>Phone call</option>
<option>Email</option>
</select>
</label>
<label>Parent / guardian name (if the patient is under 18) <input type="text" name="guardian_name"></label>
</fieldset>
<fieldset>
<legend>2. Emergency contact</legend>
<label>Name <input type="text" name="emergency_contact_name" required></label>
<label>Relationship <input type="text" name="emergency_contact_relationship" placeholder="Spouse, parent, friend"></label>
<label>Phone <input type="tel" name="emergency_contact_phone" required></label>
</fieldset>
<fieldset>
<legend>3. Insurance</legend>
<label>Insurance or health plan
<input type="text" name="insurance_provider" placeholder="Leave blank if paying yourself">
</label>
<label>Member ID <input type="text" name="member_id"></label>
<label>Group number <input type="text" name="group_number"></label>
<label>Policyholder
<select name="policyholder">
<option>Self</option>
<option>Spouse / partner</option>
<option>Parent / guardian</option>
<option>No insurance (self-pay)</option>
</select>
</label>
</fieldset>
<fieldset>
<legend>4. Care team</legend>
<label>Primary care physician <input type="text" name="primary_care_physician"></label>
<label>Preferred pharmacy (name and location) <input type="text" name="preferred_pharmacy"></label>
<label>How did you hear about us?
<select name="referral_source">
<option>Referred by a doctor</option>
<option>Friend or family</option>
<option>Search engine</option>
<option>Insurance directory</option>
<option>Other</option>
</select>
</label>
</fieldset>
<fieldset>
<legend>5. Consent</legend>
<label><input type="checkbox" name="consent_to_treatment" value="yes" required>
I consent to examination and treatment by this practice.</label>
<label><input type="checkbox" name="privacy_acknowledged" value="yes" required>
I have read the practice's privacy notice.</label>
</fieldset>
<!-- Clinical history, medications and allergies are left out on purpose:
collect them in your HIPAA-covered patient portal or EHR. -->
<!-- honeypot — bots fill every field -->
<input type="checkbox" name="botcheck" style="display:none" tabindex="-1" autocomplete="off">
<button type="submit">Submit intake form</button>
</form>How to add it
To add a Patient Intake Form to your site you need three things: a free splitforms access key, the HTML snippet above, and your key pasted into it. No backend, database, or CAPTCHA library — the form posts to one URL and every submission lands in your inbox and dashboard.
Paste the HTML above into your practice site and replace YOUR_ACCESS_KEY with the key from your splitforms dashboard. The 23 fields are grouped into five fieldsets — patient details, emergency contact, insurance, care team, consent — so the form reads as short steps.
If your practice is a HIPAA covered entity, everything a patient gives you, demographics and insurance included, is protected health information, and splitforms signs no BAA: use a system that does. Outside HIPAA's scope, still keep medical history, medications, and allergies in your patient portal or EHR and link to it from the confirmation page.
Every submission is saved to the dashboard and emailed to you on every plan, including Free. On paid plans, forward it by signed webhook to your EHR's intake API, Google Sheets, or Slack so the chart is created from the form instead of re-typed.
What's included
A patient intake form (also called a new-patient registration form) is the paperwork a patient completes before the first appointment: who they are, how to reach them and someone close to them, how the visit is paid for, who else is on their care team, and their consent to treatment. Filled in online, it arrives as one structured submission the front desk can verify and copy into the chart before the patient walks in. This template covers the administrative half of intake and deliberately leaves out medical history, medications, and allergies: splitforms is not HIPAA compliant and does not sign Business Associate Agreements, so clinical questions belong in a patient portal or EHR that does. Collect administrative intake on the web form; keep clinical history in a system that signs a BAA.
Where submissions go
Reply-to is wired to the visitor's email, so one tap on Reply answers them directly — while the built-in honeypot and automatic spam scoring filter out bots before they reach you. Every submission is emailed to your inbox and can forward to a webhook or Slack the moment a visitor hits send.
How SplitForms works
splitforms receives the submission, filters spam, saves it to your dashboard and emails you — then, on paid plans, sends it on to your webhooks and integrations. No backend infrastructure to build.
Point your form to your unique SplitForms endpoint. That's it.
We instantly capture and organize every submission in your inbox.
Send data to email, spreadsheets, CRMs, webhooks, and 7,000+ apps.
No credit card required. Set up in under 60 seconds.
Connect & automate
On paid plans, submissions can also go to Slack, Discord, Google Sheets, Notion, Airtable, Zapier or any signed webhook — and splitforms works on the platforms you build on, from WordPress and Shopify to Next.js. With Stripe connected, your forms can take payments too.
NewTake payments on your formsDeposits, bookings, order forms — submitters check out through Stripe and the money goes straight to your Stripe account. Included on every paid plan.See payment forms →Need time slots? Online booking →Questions
Yes, with the splitforms booking add-on ($100/year, 14-day free trial). Each booking page can ask its own intake questions, limited to specific services if you like, and the clinic starter set includes date of birth, health card number, reason for visit, allergies, and current medications. Answers you mark sensitive are encrypted with AES-256-GCM before they are stored, and the exact consent wording a patient agreed to is recorded. The same position applies: there is no BAA.
Add a standard <input type="file"> field and each photo is stored and linked from that patient's submission in the dashboard. File uploads are a Pro feature; on the free plan, collect the member ID, group number, and plan name as text fields, as the template does.
Yes — turn on the auto-responder (a paid feature) and it replies to the email address the patient entered, confirming their intake arrived ahead of the appointment. On the free plan your staff still get the submission notification; there's just no patient-facing reply.
There's no CAPTCHA for a patient to solve at the end of a long form. A hidden honeypot field and a rule-based content filter catch junk automatically, so a real patient finishing their intake never hits a puzzle.
A patient intake form is the document a new patient completes before the first visit. It typically records legal name, date of birth, contact details, address, emergency contact, insurance or self-pay status, primary care physician, preferred pharmacy, and consent to treatment. Clinical intake (history, medications, allergies) is often a separate section collected in the practice's EHR or patient portal.
No. splitforms is not HIPAA compliant and does not sign Business Associate Agreements, and its security page asks customers not to collect protected health information with it. If your practice is a HIPAA covered entity, collect patient intake in a system that signs a BAA. This template suits practices outside HIPAA's scope — check your own obligations, including local privacy law outside the US.
Because that is the most sensitive part of intake, and splitforms is not built for it: there is no BAA, and the owner notification email contains the submitted values. The template stops at administrative details. Add a link on your thank-you page to the portal where patients complete their clinical history.
Simple pricing
Free gives you 500 submissions for $0 — no card, no time limit. Pro is $5/month for 5,000 submissions a month, and Annual is $49/year for 15,000 a month with every Pro feature.
For side projects and indie devs.
Every paid feature, for agencies and growing products.
Every Pro feature with triple the volume — $0.27 per 1,000 at full use.
No credit card required on Free • Cancel anytime • Full pricing and FAQ
