Introducing User Segmentation — Deliver surveys and feedback forms with precise targeting using powerful User Segments. Learn more ➝

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Enter primary contact's full name
Enter primary contact's email address
Choose a password (at least 6 characters, no spaces, case-sensitive)
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user-picsrating-star crowd-logo captera-logo Rated 4.8/5 stars

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Enter primary contact's full name
Enter primary contact's email address
Choose a password (at least 6 characters, no spaces, case-sensitive)
  • Your account is being created in the
By proceeding, you agree to the Terms of Service and Privacy Policy.
Or, sign up with email

user-picsrating-star crowd-logo captera-logo Rated 4.8/5 stars

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.

  • Try 7 days for Free
  • 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. 

New Patient Registration Form Template Questions

  1. 1. Personal Information
    • Full Name
    • Date of Birth
    • Gender
    • Permanent Address
    • Mobile Number
    • Email Address
  2. 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. 3. Insurance Information
    • Insurance Provider
    • Insurance Policy Number
  4. 4. Emergency Contact
    • Full Name
    • Relationship
    • Phone Number
  5. 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. 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

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