Paperwork shouldn’t slow down patient care. A well-structured patient information sheet helps your team collect the right details upfront—without the back-and-forth.

This easy-to-use, downloadable template organizes key patient information, from demographics and insurance coverage to emergency contacts and medical history. With clear, standardized sections, it helps your team:

• Prevent billing errors by verifying insurance details early.
• Improve emergency response with up-to-date contact information.
• Ensure continuity of care by tracking past treatments, medications, and allergies.

Because better records mean better care — and less time spent on admin.

Download our free patient information sheet

Download the digital form to use online or print in practice.

Here's a breakdown of what you'll find in our patient information form.

Section 1: Patient information

This section collects a patient’s basic identifying information.


It ensures that medical records are attributed to the right patient and that all patient information is up-to-date.

Accuracy in this section is important for record-keeping, insurance processing, and enabling easy contact with patients.

• Social security number
• First name, last name, middle initial
• Date of birth
• Gender
• Marital status
• Address
• Home phone, work phone, cell phone

Section 2: Emergency contact

This section identifies an individual a patient trusts so healthcare providers can reach them in case of a medical emergency. Collecting this information is important as delays in contacting a family member, close friend, or caretaker can impact medical decisions. 

• Name
• Relationship to patient
• Home phone, work phone, cell phone

Section 3: Insurance information

This section provides the necessary insurance details for moving billing and insurance claims forward.

The insurance information collected here is crucial for ensuring medical expenses are covered according to the patient’s insurance policy.

• Policyholder’s first name
• Policyholder’s last name
• Policyholder’s social security
• Policyholder’s date of birth
• Gender
• Relationship to policyholder 
• Policyholder’s address 
• Insurance name
• Policy ID
• Group #

Is there a secondary medical insurance provider? Yes/No

• If yes, name of insurance company: 
• Policy ID: 
• Group #: 
• Policyholder’s first name: 
• Policyholder’s last name: 
• Policyholder’s social security: 
• Policyholder’s date of birth: 
• Relationship to policyholder: 

Section 4: Signature

In this section, the patient will certify the accuracy of the information provided and acknowledge that they understand their financial responsibility, insurance obligations, and copay requirements. 

I verify that the above information is factual and true to the best of my knowledge. I understand that proof of insurance and/or copay, if applicable, is due at the time of service.

Patient or Legal Guardian Signature: 

Date: 

Need more patient information?

If your practice requires a more detailed patient information sheet —including medical history, current medications, and lifestyle factors—our patient intake form template has you covered.

📌 Download the Patient Intake Form for a comprehensive, structured way to gather all the patient details you need for quality care.

Conclusion

Collecting patient details shouldn’t be a hassle. With this patient information sheet template, your team can gather essential information quickly and accurately — so nothing falls through the cracks.

Want an even easier way to collect patient information?

Freed’s AI scribe captures and organizes key details automatically, so you spend less time filling out forms and more time with your patients. Try it for free today.