New Patient Registration Form Template

Collect personal and health information from new patients and use the information to provide safe and effective medical assistance using this New Patient Registration Form template.

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Lightening fast setup

Use this new patient registration form template to seamlessly collect information from patients. Customiza the patient registration form using logos, change survey questions, and get specific information you need to improve your patient experience.

20 Questions

12Screens

11 minsto complete

New Patient Registration Form Template Questions

1. Personal Information
- Full Name
- Date of Birth
- Gender
- Permanent Address
- Mobile Number
- Email Address
2. Medical History
- Are you currently taking any medication?
  - Yes
  - No
- Do you have any known allergies
  - Yes (Please Specify)
  - No
- Do you have any chronic medical conditions?
  - Yes (Please Specify)
  - No
3. Insurance Information
- Insurance Provider
- Insurance Policy Number
4. Emergency Contact
- Full Name
- Relationship
- Phone Number
5. General Health Questions
- Are you currently experiencing any symptoms or health concerns?
  - Yes (Please Specify)
  - No
- Have you been hospitalized in the past year?
  - Yes
  - No
6. I acknowledge that the information provided is accurate and complete.
- I Agree
- I don't Agree

Create and send this Patient Feedback about Doctor Survey Template