Patient Intake Template
A new-patient intake form with demographics, insurance info, medical history, current medications, and HIPAA acknowledgment. Designed to replace a paper clipboard in the waiting room.
Drop the patient intake template into any page, customize every field in a drag-and-drop editor, and collect responses in a dashboard that is built for teams — not spreadsheets. Free forever on Foldr Forms.
Fields in this template
This template ships with 10 fields. Every field is editable — add, remove, or rename without touching code.
| Field | Type | Required |
|---|---|---|
| Full legal name | text | Required |
| Date of birth | date | Required |
| Phone | tel | Required |
email | Required | |
| Insurance provider | text | Required |
| Policy number | text | Required |
| Insurance card photo | file | Required |
| Current medications | textarea | Optional |
| Known allergies | textarea | Optional |
| HIPAA acknowledgment | checkbox | Required |
Common use cases
- New-patient clinic onboarding
- Telehealth pre-visit intake
- Dental or specialist first visit
- Therapy or counseling intake
Embed this template
Paste this snippet anywhere in your HTML and the form will render in place.
<script src="https://foldr.space/forms/embed.js" data-template="patient-intake"></script>Prefer a hosted link? Every template also gets a share URL at foldr.space/forms/patient-intake.
How to use the Patient Intake template
- 1
Copy the embed code
Grab the Foldr Forms script tag above.
- 2
Paste it in your site
Drop it into the HTML of any page where the form should appear.
- 3
Customize the fields
Open the template in the Foldr editor to tweak fields without code.
Frequently asked questions
Is Foldr HIPAA compliant for patient data?
Foldr supports HIPAA-compliant configurations with a signed BAA on the Business plan, including encryption at rest, audit logs, and access controls.
Can patients upload insurance cards?
Yes. The file field accepts photos up to 10 MB and the image is encrypted before it lands in your dashboard.
Can I pre-send the form before the appointment?
Yes. Generate a unique magic link per appointment so the patient completes intake from home and the front desk skips data entry.