new patient intake form template pdf

Medical Practice Patient Registration and Consent Form

Instructions for Use

• Print this document and complete all fields in blue or black ink, or complete the digital fields prior to printing for signature.
• Ensure that all insurance information is verified against your current identification card before submitting this form to the administrative staff.
• Review the privacy and consent clauses thoroughly; by signing, you acknowledge your legal obligations regarding payment and the disclosure of health information.

Parties & Definitions

This Agreement is entered into by and between [Practice Name] ("Provider") and [Patient Full Legal Name] ("Patient") (or the Patient's legal representative, [Representative Name], if applicable).

Patient Information: Full Name: [] Date of Birth: [] Address: [] Phone: [] Email: [] Emergency Contact Name: [] Emergency Contact Phone: [__________]

Operative Clauses

1. Consent for Treatment: The Patient voluntarily consents to such care, diagnostic procedures, and medical treatment as may be deemed necessary or advisable by the Provider. The Patient understands that the practice of medicine is not an exact science and that no guarantees have been made regarding the results of treatments.

2. Insurance and Financial Responsibility: The Patient understands that they are ultimately responsible for all charges incurred. If the Patient has insurance, the Provider will bill the insurance carrier as a courtesy; however, the Patient remains responsible for any co-pays, deductibles, or non-covered services.

   • I authorize payment of medical benefits to the Provider.
   • I agree to pay all balances within [__] days of receiving a statement.

3. Privacy and HIPAA Acknowledgment: The Patient acknowledges receipt of the Provider’s Notice of Privacy Practices, which describes how health information may be used and disclosed. The Patient understands they have the right to request restrictions as to how their health information is used.

4. Communication Policy: The Patient consents to receive communications from the Provider via:

   • Phone / Voicemail
   • Email
   • Text Message (Standard messaging rates may apply)

5. Cancellation Policy: The Patient agrees to provide at least [] hours' notice for any appointment cancellations. Failure to provide such notice may result in a fee of $[____] charged to the Patient’s account.

Signature & Acknowledgment

By signing below, I certify that the information provided is true and accurate to the best of my knowledge, and I agree to the terms outlined above.

Signature: __________ Printed Name: [] Title/Relationship: [] Date: [__________]

Legal Disclaimer: This document is a general framework intended for informational purposes and does not constitute legal advice. Requirements for patient intake vary significantly by state and specialty; consult with qualified legal counsel to ensure compliance with local, state, and federal regulations, including HIPAA and state-specific medical practice acts.