Patient Intake Form Template for United States

A Patient Intake Form is a legal and medical document used in United States healthcare settings to collect essential patient information, including demographics, medical history, insurance details, and various consents required by federal and state laws. The document must comply with HIPAA regulations and other relevant healthcare laws, ensuring proper collection and protection of patient information while meeting both clinical and legal requirements for healthcare delivery.

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

Typically:

With Genie AI:

£0

Download a Standard Patient Intake Form

Download a United States-compliant Patient Intake Form or see Genie's full template library.

Get template free

Review your own Patient Intake Form

Let Genie AI identify missing terms, unusual language, compliance issues and more.

Upload to review

Your data doesn't train Genie's AI

You keep IP ownership of your docs

4.6 / 5

4.8 / 5

What is a Patient Intake Form?

The Patient Intake Form serves as the primary document for gathering crucial patient information in U.S. healthcare settings. This document is typically used during a patient's first visit or when updating records, collecting comprehensive information about the patient's demographics, medical history, insurance details, and emergency contacts. The form must comply with federal regulations including HIPAA, ADA, and state-specific healthcare laws. It provides the foundation for creating the patient's medical record and ensures the healthcare provider has necessary information for proper care delivery and legal compliance.

What sections should be included in a Patient Intake Form?

1. Patient Demographics: Basic patient information including name, DOB, address, contact details

2. Emergency Contact Information: Primary and secondary emergency contacts

3. Insurance Information: Primary and secondary insurance details

4. Medical History: Past medical conditions, surgeries, medications

5. HIPAA Acknowledgment: Patient acknowledgment of privacy practices

6. Consent for Treatment: General consent for medical treatment

What sections are optional to include in a Patient Intake Form?

1. Language Preference: Required for facilities serving diverse populations - captures patient's preferred language for communication

2. Advanced Directives: Optional for adult patients, especially in primary care settings - documents patient's medical care preferences

3. Research Participation: For use in academic medical centers or research facilities - contains consent for research participation

What schedules should be included in a Patient Intake Form?

1. Notice of Privacy Practices: Detailed HIPAA privacy information

2. Financial Policy: Payment terms and insurance processing information

3. Patient Rights and Responsibilities: Outline of patient rights and responsibilities under care

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

Cost

Free to use

Find the exact document you need

No matches found.

Electronic Intake Forms

Legal framework for electronic intake forms compliant with US federal and state regulations, governing digital information collection and processing.

How a Fast-Growing Real Estate Company Uses Genie AI to Save $50,000 Per Year in Legal Fees

Generate a Bespoke Document

Download a Standard Patient Intake Form

Review your own Patient Intake Form

What is a Patient Intake Form?

What sections should be included in a Patient Intake Form?

What sections are optional to include in a Patient Intake Form?

What schedules should be included in a Patient Intake Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Electronic Intake Forms

Client Intake Form Law Firm

Law Office Intake Form

Buyer Intake Form

Nonprofit Client Intake Form

Real Estate Intake Form

Online Intake Forms For Massage Therapy

Consignment Intake Form

Creative Project Intake Form

Nonprofit Intake Form

Veterinary Intake Form

Financial Coaching Intake Form

Event Planning Intake Form

Virtual Assistant Intake Form

Massage Client Intake Form

Hypnotherapy Client Intake Form

Home Care Intake Form

Catering Intake Form

Case Intake Form

Referral Intake Form

Inventory Intake Form

Biopsychosocial Intake Form

Wellness Intake Form

Vehicle Intake Form

Real Estate Buyer Intake Form

Marriage Counseling Intake Form

Financial Intake Form

Consulting Intake Form

Case Management Intake Form

Order Intake Form

Bookkeeping Client Intake Form

Salon Client Intake Form

Creative Intake Form

Esthetician Client Intake Form

Client Intake Form

Lead Intake Form

Employment Intake Form

Vendor Intake Form

Intake Assessment Form

Clinical Intake Form

Genie’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Solutions

Legal Resources

Use Cases

Information