Good documentation makes great care easier.

Patient intake shouldn’t feel like a chore—it should set the stage for seamless, personalized care .A well-structured patient intake form ensures you have all the necessary details upfront, from medical history to insurance information, so you can focus on what really matters: helping your patients.

Of course, paperwork shouldn’t slow you down. That’s why we put together this free, easy-to-use medical intake form template—so you can get the info you need without the hassle.

Let’s make onboarding easier. Below, we’ll outline what’s inside the template and how each section contributes to a seamless intake process.

Download your free patient intake form sample template

📌 Download Now: Get a printable new client intake form PDF for easy use in your practice.

Why use our patient intake form template?

• Editable & Printable – Customize it to fit your practice's specific needs.
• Time-Saving – Standardized format ensures efficient patient onboarding.
• HIPAA-Compliant – Designed with privacy and legal considerations in mind.

What’s inside a client intake form

Each section of the this patient or client intake form captures relevant details without unnecessary complexity.

Here’s what you’ll find:

1. New Patient Information

This section collects basic identifying details, ensuring proper record-keeping and patient identification.

• Full Name
• Date of Birth
• Gender
• Contact Information (Phone, Email)
• Home Address
• Emergency Contact Details

2. Insurance & Billing Information

Ensures accurate processing of insurance claims and payments.

• Primary Insurance Provider
• Policy Number & Group Number
• Secondary Insurance (if applicable)
• Responsible Party for Billing (if different from the patient)

3. Medical History

Provides critical background for treatment planning and risk assessment.

• Current Medications & Dosages
• Past Surgeries & Procedures
• Chronic Conditions (e.g., Diabetes, Hypertension, Asthma, etc.)
• Family Medical History
• Known Allergies (Medication, Food, Environmental)

4. Current Health Concerns

Helps providers understand the reason for the patient’s visit and any symptoms they’re experiencing.

• Primary Reason for Visit
• Duration & Severity of Symptoms
• Recent Hospitalizations or ER Visits

5. Lifestyle & Social History

Gives insight into factors that may affect the patient’s health.

• Smoking, Alcohol, and Drug Use
• Exercise & Dietary Habits
• Occupation & Work-Related Health Concerns

6. Consent & HIPAA Acknowledgment

Ensures compliance with privacy regulations and informed consent for treatment.

• Consent for Treatment
• HIPAA Privacy Policy Acknowledgment
• Signature & Date

What does a completed medical intake form look like?

A client intake form provides a clear, structured overview of a patient’s personal, medical, and insurance details.

Here's a sample template you can follow:

1. Patient Information

• Full Name: John Doe
• Date of Birth: 01/15/1985
• Gender: Male
• Contact Information: (555) 123-4567 | johndoe@email.com
• Home Address: 123 Main St, Springfield, IL 62701
• Emergency Contact: Jane Doe (Spouse) – (555) 987-6543

2. Insurance & Billing Information

• Primary Insurance Provider: Blue Cross Blue Shield
• Policy Number & Group Number: 123456789 | Group 98765
• Secondary Insurance: None
• Responsible Party for Billing: John Doe

3. Medical History

• Current Medications & Dosages:
  • Metformin 500mg (once daily)
  • Lisinopril 10mg (once daily)
• Past Surgeries & Procedures: Appendectomy (2010)
• Chronic Conditions: Type 2 Diabetes, Hypertension
• Family Medical History:
  • Father – Heart Disease
  • Mother – Type 2 Diabetes
• Known Allergies: Penicillin (causes rash)

4. Current Health Concerns

• Primary Reason for Visit: Annual checkup, monitoring blood sugar levels
• Duration & Severity of Symptoms: Occasional dizziness in the morning (last 3 weeks)
• Recent Hospitalizations or ER Visits: None

5. Lifestyle & Social History

• Smoking, Alcohol, and Drug Use:
  • Smokes occasionally (2-3 cigarettes/week)
  • Drinks socially (2-3 drinks/month)
• Exercise & Dietary Habits:
  • Walks 30 minutes daily, follows a low-carb diet
• Occupation & Work-Related Health Concerns:
  • Office worker, experiencing mild back pain from prolonged sitting

6. Consent & HIPAA Acknowledgment

• Consent for Treatment: ✅ Yes
• HIPAA Privacy Policy Acknowledgment: ✅ Yes
• Signature & Date: John Doe | 02/15/2025

Download your free client intake form PDF

📌 Download Now: Click here to get the form and simplify your patient or client intake process.

Use AI scribes for the client intake process

Forms are fine. But what if patient intake could write itself? Freed’s AI scribe captures details instantly — no typing, no hassle.
No more flipping through traditional paper forms forms or chasing down missing details. Freed’s AI scribe records everything in real time — so nothing gets lost, and you do less typing.

These AI-powered tools include:

• Auto-filled sections: Demographics, medical history, and insurance details are instantly populated.
• Seamless EHR integration: Patient data syncs directly with top electronic health records.
• Customizable fields: Adapt the form to meet your practice’s specific intake requirements.
• HIPAA-compliant security: Keeps sensitive patient information protected at all times.
• Cross-device accessibility: Use on desktops, tablets, or smartphones for in-person or virtual visits.

For example, during a new patient intake, the AI highlights allergies, current medications, and pre-existing conditions while filtering out unrelated information.

This not only speeds up the intake process but ensures clinicians have complete and accurate information—right from the start.

"I have found this to be extremely accurate and customizable. I can get a document that is arranged for an intake assessment as well as for a progress note. I can even train the scribe to write a note for counseling or psychotherapy where I don't need all of the mentions about medications, and lab work, etc because I am talking about a therapeutic issue.” — Vera T., Addictions Physician

Taking the next step

Streamlined patient intake doesn’t have to mean more paperwork or lost time.

This patient intake form template—or an AI scribe—helps you gather essential details quickly and accurately, so you can focus on building patient relationships from the very first visit.

Fewer forms. Less typing. More time for your patients. That’s the way it should be. Try our AI scribe for free.