Medical Intake Form Template for England and Wales

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Key Requirements PROMPT example:

Medical Intake Form Template

I need a Medical Intake Form Template for my new private dental practice opening in March 2025, compliant with UK GDPR and suitable for both adult and pediatric patients, with specific sections for dental history and orthodontic treatment.

Document background

The Medical Intake Form Template serves as a crucial first point of contact between healthcare providers and patients in England and Wales. This document is designed to collect comprehensive patient information while ensuring compliance with UK GDPR, the Data Protection Act 2018, and various healthcare regulations. The template includes sections for personal information, medical history, current medications, allergies, and necessary consents. It supports healthcare providers in maintaining accurate records and delivering appropriate care while protecting patient privacy and confidentiality.

Suggested Sections

1. Patient Personal Information: Basic demographic details including full name, date of birth, address, contact numbers, email, NHS number, and identification details

2. Emergency Contact Details: Name, relationship, contact numbers and address of primary and secondary emergency contacts

3. Medical History: Comprehensive list of previous medical conditions, surgeries, hospitalizations, and ongoing health issues

4. Current Medications: Detailed list of current prescriptions, over-the-counter medications, and supplements including dosages and frequencies

5. Allergies and Reactions: Documentation of all known allergies to medications, substances, or materials, including the type of reaction experienced

6. Consent Statement: GDPR-compliant declaration for processing personal and medical data, including specific consent for different types of data processing

Optional Sections

1. Insurance Information: Details of private medical insurance including policy number, provider, and coverage details

2. Family Medical History: Information about hereditary conditions and significant health issues in immediate family members

3. Lifestyle Information: Details about smoking status, alcohol consumption, exercise habits, occupation, and other lifestyle factors affecting health

Suggested Schedules

1. Privacy Notice: Detailed information about how personal data is collected, processed, stored, and shared, including patient rights under GDPR

2. Medical Records Release Authorization: Form authorizing the release and transfer of medical records from previous healthcare providers

3. Practice Policies: Documentation of clinic policies regarding appointments, cancellations, fees, and other administrative matters

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare
Medical Research
Mental Health Services
Allied Health Services

Relevant Teams

Medical Administration
Compliance
Legal
Information Governance
Patient Services

Relevant Roles

General Practitioner
Practice Manager
Medical Secretary
Compliance Officer
Data Protection Officer

Find the exact document you need

Medical Intake Form

A standardized template for collecting patient information in England and Wales, compliant with UK healthcare and data protection regulations.

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Authors

Alex Denne

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