Patient Intake Form Template for India

Create a bespoke document in minutes, or upload and review your own.

4.6 / 5

4.8 / 5

Let's create your Patient Intake Form

1. Select your governing law and document type:

2. Enter your key requirements:

3. Create your document to edit, review or download

Get your first 2 documents free

Your data doesn't train Genie's AI

You keep IP ownership of your information

Key Requirements PROMPT example:

Patient Intake Form

"I need a Patient Intake Form for my new mental health clinic opening in Mumbai in January 2025, ensuring compliance with Mental Healthcare Act 2017 and including sections for mental health history, medication tracking, and emergency psychiatric care consent."

Document background

The Patient Intake Form is a crucial document used across Indian healthcare facilities to initiate formal medical care relationships. It complies with Indian healthcare regulations, including the Clinical Establishments Act 2010 and relevant data protection laws. This document is typically used during a patient's first visit or hospital admission, collecting comprehensive information about their medical history, personal details, insurance coverage, and emergency contacts. The form includes mandatory consent sections for treatment and data handling, aligning with Indian medical practice regulations and privacy laws. It serves as both a legal record and a clinical tool, enabling healthcare providers to deliver appropriate care while maintaining regulatory compliance.

Suggested Sections

1. Patient Personal Information: Basic demographic details including name, date of birth, gender, contact information, government ID numbers, and preferred language

2. Emergency Contact Information: Details of primary and secondary emergency contacts including relationship to patient

3. Insurance Information: Health insurance details, policy numbers, and billing information

4. Medical History: Patient's past medical conditions, surgeries, hospitalizations, and chronic conditions

5. Current Medications: List of current medications, dosages, and supplements

6. Allergies and Reactions: Known allergies to medications, foods, or environmental factors

7. Family Medical History: Relevant family medical conditions and genetic predispositions

8. Lifestyle Information: Smoking status, alcohol consumption, exercise habits, and dietary preferences

9. Primary Care Information: Details of current or previous healthcare providers

10. Consent and Authorization: Legal declarations for treatment consent, information sharing, and privacy policy acknowledgment

Optional Sections

1. Mental Health History: Additional section for mental health conditions and treatments, used when facility provides mental health services

2. Pregnancy History: For female patients of reproductive age, detailing previous pregnancies and related complications

3. Immunization Record: Detailed vaccination history, particularly important for pediatric patients

4. Occupational Health Information: Work-related health risks and exposures, used when relevant to patient's health conditions

5. Alternative Medicine Usage: Information about use of traditional medicine, ayurveda, or other alternative treatments

6. Language Assistance: For patients requiring interpreter services or communication assistance

7. Religious/Cultural Preferences: Special considerations for treatment based on religious or cultural beliefs

8. Advanced Directives: For adult patients who wish to specify treatment preferences and end-of-life care decisions

Suggested Schedules

1. Privacy Policy: Detailed explanation of how patient information is collected, used, and protected

2. Patient Rights and Responsibilities: Comprehensive list of patient rights and obligations under Indian healthcare laws

3. Fee Schedule: List of standard charges for common procedures and services

4. Hospital Policies: Key institutional policies affecting patient care and facility usage

5. Medication History Form: Detailed template for recording current and past medication usage

6. Medical Records Release Authorization: Standard form for requesting transfer of medical records

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 Insurance

Hospital Administration

Legal Services

Healthcare Technology

Public Health

Mental Healthcare

Pharmaceutical

Medical Research

Healthcare Education

Relevant Teams

Reception

Patient Registration

Medical Records

Compliance

Legal

Quality Assurance

Information Technology

Patient Relations

Clinical Operations

Insurance Processing

Data Management

Administrative Services

Relevant Roles

Medical Doctor

Nurse

Hospital Administrator

Medical Records Officer

Front Desk Executive

Healthcare Facility Manager

Compliance Officer

Legal Counsel

Insurance Coordinator

Patient Care Coordinator

Clinical Director

Quality Assurance Manager

Data Protection Officer

Healthcare IT Manager

Patient Relations Manager

Find the exact document you need

Massage Therapy Consultation Form

An Indian-compliant massage therapy intake form combining medical screening, client consent, and liability provisions under Indian healthcare regulations.

How Genie AI reduced drafting time by 75% for a legal firm

Let's create your Patient Intake Form

Authors

Alex Denne

Find the exact document you need

Massage Therapy Consultation Form

Massage Client Record Card

Mediation Intake Form

Health Coach Intake Form

Chair Massage Waiver Form

Real Estate New Client Intake Form

Salon Intake Form

Work Intake Form

Computer Repair Intake Form

Yoga Intake Form

Naturopathic Intake Form

Event Intake Form

Chiropractic Patient Intake Form

Consulting Client Intake Form

Legal Intake Form

Physical Therapy Intake Form

Content Intake Form

Virtual Assistant Client Intake Form

Marketing Intake Form

Event Planning Client Intake Form

Nutrition Intake Form

Counseling Intake Form

Spray Tan Intake Form

Marketing Client Intake Form

Client Intake Assessment Form

Massage Medical History Form

Real Estate Intake Form

Veterinary Intake Form

Hypnotherapy Client Intake Form

Home Care Intake Form

Catering Intake Form

Referral Intake Form

Inventory Intake Form

Biopsychosocial Intake Form

Vehicle Intake Form

Real Estate Buyer Intake Form

Marriage Counseling Intake Form

Financial Intake Form

Order Intake Form

Bookkeeping Client Intake Form

Creative Intake Form

Esthetician Client Intake Form

Client Intake Form

Lead Intake Form

Employment Intake Form

Vendor Intake Form

Clinical Intake Form

Procurement Intake Form

Patient Intake Form

Download our whitepaper on the future of AI in Legal

Genie’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security

Innovation in privacy:

Want to know more?

Commercial

Employment

IP

Administration

Finance

R&D

Use Cases