patient intake form template word pdf

Medical Practice Patient Registration and Intake Agreement

Instructions for Use

• Complete all fields marked with brackets using accurate personal or clinical information.
• Ensure the patient or authorized legal representative reviews all clauses before signing.
• Print a copy for the patient’s records and retain the original in the secure medical file.

Parties and Definitions

This Intake Agreement ("Agreement") is entered into by and between [Practice/Clinic Name] ("Provider") and [Patient Full Legal Name] ("Patient") as of [Date].

Operative Clauses

1. Patient Information:

   • Full Name: [__________]
   • Date of Birth: [__________]
   • Primary Phone: [__________]
   • Email Address: [__________]
   • Emergency Contact Name: [__________]
   • Emergency Contact Phone: [__________]

2. Insurance and Billing:

   • Primary Insurance Carrier: [__________]
   • Policy ID Number: [__________]
   • The Patient agrees to provide current insurance information and authorizes the Provider to bill the insurance carrier directly. The Patient remains responsible for any co-pays, deductibles, or non-covered services.

3. Medical History and Disclosure:

   • Current Medications: [__________]
   • Known Allergies: [__________]
   • Chronic Conditions: [__________]
   • The Patient warrants that the medical history provided is true, accurate, and complete to the best of their knowledge.

4. Consent to Treatment:

   • The Patient voluntarily consents to diagnostic procedures, examinations, and medical treatments as deemed necessary by the Provider.
   • I consent to routine diagnostic testing.
   • I decline the following specific procedures: [__________]

5. Privacy and HIPAA Compliance:

   • The Provider shall maintain the confidentiality of all Protected Health Information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA). A copy of the Notice of Privacy Practices has been [ ] provided / [ ] reviewed by the Patient.

6. Cancellation and No-Show Policy:

   • The Patient agrees to provide at least [Number] hours of notice for appointment cancellations. Failure to provide such notice may result in a fee of $[Amount].

7. Governing Law:

   • This Agreement shall be governed by the laws of the state of [State Name].

Signature and Acknowledgment

By signing below, I certify that I have read, understood, and agreed to the terms set forth in this document.

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

Legal Disclaimer: This document is a general framework and does not constitute legal advice. Requirements for patient intake vary significantly by jurisdiction and specialty. Consult with qualified healthcare counsel to ensure compliance with local, state, and federal regulations.