Free compliance & forms tool
Patient Intake Form Template: Build and Print Your Own
A patient intake form collects what a practice needs before a first visit: contact details, medical history, medications, allergies, consents and a signature. Pick a preset below (med spa, plastic surgery, IV and weight management, general or short), switch sections on or off, add your practice name, and print a clean new patient intake form. The setup is saved in the page address, so you can share it.
Prepared by Prospyr · Reviewed October 3, 2026 · Free, no sign-up, runs in your browser
Your form
14sections
37 questions and fields, plus the signature block. Prints on letter paper, usually 2 to 3 pages.
The preview below is exactly what prints.
Template: review and edit with your medical director and counsel before giving it to patients. It collects history; it does not decide who can be treated.
Form preview
[Practice name]
New Patient Intake Form
Please print clearly. Leave blank anything that does not apply. Your answers are kept confidential.
Patient information
Emergency contact
How you found us
How did you hear about us?
Friend or family
Another patient
Google or search
Social media
Another provider
Other
Reason for your visit
What brings you in today?
What would you like to change or improve?
Medical history
Check any that apply, now or in the past.
High blood pressure
Heart condition
Diabetes
Thyroid condition
Autoimmune condition
Bleeding or clotting disorder
Keloid or abnormal scarring
Cold sores or herpes
Neuromuscular condition
Seizures
Liver condition
Kidney condition
Cancer
Anxiety or depression
Skin condition
Other
Details for anything checked
Medications, supplements and allergies
Current prescription medications, including doses
Over-the-counter medications, vitamins and supplements
Allergies
Latex
Lidocaine or local anesthetics
Antibiotics
Adhesives or tape
Fragrance or skincare ingredients
None known
Other
Surgical and treatment history
Surgeries and hospital stays (what and when)
Previous aesthetic treatments
Neurotoxin
Dermal filler
Laser or light treatment
Chemical peel
Microneedling
Body contouring
Implants
Plastic surgery
Other
Skin and sun history
Sun exposure
Tanning bed use
Recent sunburn
Recent tan
Daily sunscreen
Current skincare products and prescription topicals
Have you taken oral isotretinoin or another oral retinoid? YesNoIf yes, when: ____________
Pregnancy and breastfeeding
Are you pregnant or trying to become pregnant? YesNo
Are you breastfeeding? YesNo
Photo consent
Clinical photos are part of your medical record and help us track your results.
Marketing use
I do not allow my photos to be used outside my record
I allow use of photos in which I cannot be identified
I allow use of photos with my written permission each time
Consent to evaluation and treatment
I have answered these questions truthfully and completely. I will tell the practice about any change in my health or medications. I understand that treatment plans, risks and costs are discussed and agreed to before any treatment.
Financial and cancellation policy
I have read the practice's financial and appointment cancellation policy and I understand it. Policy summary: ____________________________________________.
Notice of Privacy Practices
I received this practice's Notice of Privacy Practices, which explains how my health information may be used and shared.
Communication
OK to leave a detailed voicemail
OK to text appointment reminders
OK to email
Signature
New patient intake form: sections you can choose from
The builder has 14 sections. Each one prints as a block with fill-in lines or check boxes:
- Who the patient is: patient information, emergency contact, how they found you.
- Why they came: the reason for the visit and what they want to change.
- Medical history form content: conditions checklist, medications and supplements, allergies, surgical and treatment history.
- Aesthetic and wellness extras: skin and sun history, pregnancy and breastfeeding, lifestyle, weight management history.
- Consents and policies: photo consent, consent to evaluation and treatment, financial and cancellation policy, Notice of Privacy Practices acknowledgment.
A signature block is always added at the end.
Medical intake form presets by practice type
| Preset | Sections | Good for |
|---|---|---|
| Med spa | 13 | Injectables, lasers and skin treatments |
| Plastic surgery consult | 12 | Surgical consultations |
| IV and weight management | 10 | Wellness and weight programs |
| General new patient | 10 | A broad first-visit packet |
| Short form | 5 | Quick return or walk-in visits |
Start from the closest preset and adjust. Everything you choose, plus your practice name and title, is stored in the page address, so you can bookmark the setup or send it to a colleague. No patient information is ever collected or stored by the page.
Patient intake form template: edit it before you use it
This is a starting template. The questions are common in aesthetic and wellness practices, but the wording of screening questions, consents and policies belongs to your medical director and counsel, and state rules differ. Print it, mark it up, and have the people who own your protocols approve the version you put in front of patients.
Paper forms are retyped into the chart. A digital intakeform is completed on the patient's phone before the visit and goes straight into the record that charting uses, so the front desk does not retype anything.
Frequently asked questions
What should a patient intake form include?
Patient and emergency contact details, the reason for the visit, medical history, current medications and allergies, prior surgeries or treatments, and signed acknowledgments. Aesthetic practices usually add skin and sun history and a pregnancy and breastfeeding question. Practices that bill add insurance or payment details.
What is the difference between a patient intake form and a medical history form?
An intake form is the whole first-visit packet, including contact details, consents and policies. A medical history form is the part of it that covers conditions, medications, allergies and prior procedures. This builder lets you print either: choose all sections for a full intake, or only the medical history sections.
Do patients have to sign anything about privacy?
A provider with a direct treatment relationship must give the patient its Notice of Privacy Practices by the first service and make a good faith effort to get a written acknowledgment of receipt. If it cannot get one, it must document its efforts and why (45 CFR 164.520(c)(2)). The Notice of Privacy Practices section of this template provides the acknowledgment.
Can I use this as a new patient intake form for a med spa?
Yes. The med spa preset includes history, medications and allergies, prior aesthetic treatments, skin and sun history, pregnancy and breastfeeding, photo consent and a financial policy. Have your medical director review the wording first, because screening questions and consent language are set by your protocols and state rules.
Does this form decide who can be treated?
No. It collects information. The provider reviews the answers and decides what is appropriate for each patient, and the form does not score or screen anyone in or out.
Is a paper form or a digital form better?
Digital forms remove retyping, can be completed before the visit and are searchable in the chart; paper works for a walk-in or a backup. Whatever you use, the answers have to end up in the patient record. A printed form is a good fallback and a good way to draft the questions you will later put online.
Sources and scope
- 45 CFR 164.520: Notice of privacy practices for protected health information (eCFR)
Paragraph (c)(2): a provider with a direct treatment relationship provides the notice no later than the first service and makes a good faith effort to obtain a written acknowledgment of receipt.
Template: review and edit with your medical director and counsel before giving it to patients. The forms collect information and do not screen, diagnose or decide who can be treated. Consent and policy language varies by state.