New Patient Registration Form
A new patient registration form is the longest form you'll ever ask someone to fill in, so it should be the only one. Details, history, medication, insurance and next of kin, in short steps.
For clinics, practices and healthcare providers.
Completed at home, not on a clipboard
Registration forms filled in at a reception desk are rushed, illegible and incomplete - and the medication list, the part that matters most clinically, is the part people can't remember without the packets in front of them.
Sent as a link before the first appointment, the same form comes back typed, complete, and filled in at a kitchen table with the prescriptions to hand. You also get it in advance, so a flagged allergy or a mobility need changes the plan before the patient arrives.
Know who's coming, and what they need
A name is the easy half. The awkward half - dietary needs, accessibility, emergency contacts, sizes - is the half that ruins a day when it's missing, and the half nobody thinks to send you.
So the form asks. Once, at registration, when the person actually knows the answer.
Paperwork before the appointment, in the patient's own time
Forms filled in at reception are rushed, incomplete and hand-written. The same questions sent with the appointment reminder come back typed, complete and read at home - and you get the first ten minutes of the appointment back.
They also arrive before you need them, so a flagged medication or a mobility need changes the plan in advance rather than in the room.
Everybody's details, exportable
One download gives you the whole list as a spreadsheet - for a check-in sheet, a name badge run, a caterer's headcount or a mail merge. No copying out of an inbox.
Make it yours in a minute
Change the wording, drop the questions you don't need, add the ones you do, put your own colour on it. Saving publishes it, and you get a link to paste into your website, your email signature or a message. Responses land in your dashboard and download as a spreadsheet whenever you want them.
What this template asks
- Full name
- Preferred name
- Date of birth
- Sex registered at birth
- Gender, if different
- Home address
- Mobile number
- Email address
- Next of kin - name and relationship
- Next of kin - phone
- Previous doctor or practice
- Do you need an interpreter?
- Which language?
- Have you ever been diagnosed with any of these?
- Details, including when diagnosed
- Previous operations and dates
- Significant family history
- All medication you take
- Allergies and what happens
- Smoking
- Alcohol
- Exercise
- How will your care be funded?
- Insurer and policy number
- You may share information with my previous doctor for continuity of care
- The information I have given is accurate and complete
More Healthcare forms
Questions
Can we use this for health information?
Responses are encrypted in transit and stored in your account, never shared or used for advertising - but you remain the data controller. Ask only what you need clinically, publish what you keep and for how long, and confirm your obligations under HIPAA, UK GDPR or your local rules first.
How do we get this into our clinical system?
Export as CSV and import, or use the REST API to pull responses. Either way it removes the retyping step, which is where most registration errors come from.
Can I stop registrations when we're full?
Yes. Close the form and the link shows a short closed page, so nobody registers for a place that doesn't exist. Reopen it in one click if space frees up.
Can I collect one registration per person or per group?
Either. Many people ask for the group size and the names in one text box; others publish the link and ask everyone to fill it in individually.
Can I get the list as a spreadsheet?
Yes - one click exports every response as CSV, which opens in Excel, Numbers or Google Sheets.
Can I use this for patient information?
Responses are stored in your account, never shared and never used for advertising, and pages are served over encrypted connections. You remain the controller of that data: ask only what you need, say what you keep, and confirm your obligations (HIPAA, UK GDPR or local equivalent) before collecting health information on a web form.
Publish your new patient registration form today
Start from this template and change anything you like. Free to begin.