Patient Intake Form template
The public half of a new-patient intake: name, how to reach them, new or returning, and when the clinic should call. Clinical history stays off this form.
What your visitor sees
Plain semantic HTML rendered through the same default form theme Core Forms applies on the front-end. Try it — this demo confirms inline and sends nothing.
Demo only. On your site, the same markup wires into the normal Core Forms action loop — email, Slack, Google Sheets, webhook, whatever you configure.
The HTML behind it
Copy this block, paste into Core Forms → Add New Form → Fields tab, save. Field names map to merge tags automatically in your action templates.
<p>
<label for="cf-intake-name">Your name <span aria-hidden="true">*</span></label>
<input type="text" id="cf-intake-name" name="NAME" autocomplete="name" required aria-required="true" />
</p>
<p>
<label for="cf-intake-email">Email address <span aria-hidden="true">*</span></label>
<input type="email" id="cf-intake-email" name="EMAIL" autocomplete="email" required aria-required="true" />
</p>
<p>
<label for="cf-intake-phone">Phone <span aria-hidden="true">*</span></label>
<input type="tel" id="cf-intake-phone" name="PHONE" autocomplete="tel" required aria-required="true" />
</p>
<p>
<label for="cf-intake-status">Are you a new or returning patient? <span aria-hidden="true">*</span></label>
<select id="cf-intake-status" name="PATIENT_STATUS" required aria-required="true">
<option value="">Choose one</option>
<option>New patient</option>
<option>Returning patient</option>
</select>
</p>
<p>
<label for="cf-intake-location">Preferred location <span aria-hidden="true">*</span></label>
<select id="cf-intake-location" name="LOCATION" required aria-required="true">
<option value="">Choose one</option>
<option>Main clinic</option>
<option>North clinic</option>
<option>No preference</option>
</select>
</p>
<p>
<label for="cf-intake-date">Preferred date</label>
<input type="date" id="cf-intake-date" name="PREFERRED_DATE" />
</p>
<p>
<label for="cf-intake-time">Best time to call <span aria-hidden="true">*</span></label>
<select id="cf-intake-time" name="CONTACT_TIME" required aria-required="true">
<option value="">Choose one</option>
<option>Morning</option>
<option>Afternoon</option>
<option>Evening</option>
</select>
</p>
<p>
<label for="cf-intake-access">Access need for the visit</label>
<select id="cf-intake-access" name="ACCESS">
<option value="">None to mention</option>
<option>Step-free access</option>
<option>Interpreter</option>
</select>
</p>
<p>
<label><input type="checkbox" name="CONTACT_CONSENT" value="yes" required aria-required="true" /> You may contact me about this request.</label>
</p>
<p>
<button type="submit">Request a call</button>
</p>
What this patient intake form template is for
A patient intake form, in a clinic, collects health information: symptoms, medications, history, insurance details. That information is protected, under HIPAA in the United States and under health-data rules elsewhere, and a general WordPress form does not supply the hosting, access controls, or agreements that handling it requires. This template does not cross that line.
What a website can do is the administrative half. Who is asking, whether they are new, which location they want, and when to call them back. The clinic takes the medical history by phone, in person, or inside the system built for it. If the job is only "request a time," the clinic appointment request template is the shorter version of the same idea.
Every field, and why it's there
| Field | Type | Required | Why it's there |
|---|---|---|---|
| Your name | text | Yes | The name the clinic should use when they call back. |
| Email address | email | Yes | Where the acknowledgement goes. |
| Phone | tel | Yes | Required here because the next step is a phone call, not a chart. |
| New or returning | select | Yes | Routes a first visit differently from a follow-up. It is not a diagnosis. |
| Preferred location | select | Yes | Swap the options for the clinics you actually run. |
| Preferred date | date | Optional | A preference, not a booked slot. |
| Best time to call | select | Yes | When someone at the desk should phone. |
| Access need for the visit | select | Optional | Step-free access or an interpreter. Not a description of a condition. |
| Consent | checkbox | Yes | Permission to reply about this request. Not a records release. |
From this HTML to a working form
- 1
Paste the markup and rename the locations
Core Forms, Add New Form, Fields tab. Replace Main clinic and North clinic with your real sites. Leave symptoms, medications, and insurance off the form.
- 2
Tell them this is a request, not a booking
Set the confirmation to say the clinic will call to confirm. Do not say the appointment is booked unless a calendar actually reserved it.
- 3
Send the request to the desk
An email action to the front desk is enough. Slack works if that is where the desk already looks. Do not forward the row into a general marketing list.
Three upgrades worth considering
Read the line this form does not cross
The appointment-request guide explains why symptoms, history, and insurance stay off a public WordPress form.
Patient appointment request guide →Use the shorter callback form
If you do not need location or new-versus-returning, the clinic appointment request template is the smaller version.
Clinic appointment request template →Word the consent checkbox on purpose
This checkbox is permission to reply about the request. It is not a records release and it is not a newsletter signup.
Consent pattern →Patient Intake Form template questions
What is a patient intake form?
In a clinic it is the form that collects who the patient is and the health information the visit needs. On a public website, only the first half belongs: identity, contact, location, and when to call. Symptoms, medications, diagnoses, and insurance details belong in the practice's clinical system.
Why does this template leave out medical history?
Health information is regulated. A form plugin does not make a WordPress host compliant with HIPAA or with other health-data laws. Collecting that history on this form would create a record the site is not set up to protect.
Can I add an insurance field later?
Not on this form. Member IDs and card photos are still sensitive, and they are not required to schedule a callback. Take them on the phone or in the system your practice already uses for billing.
The template is free. The plumbing is the product.
Core Forms turns this HTML into stored submissions, spam-filtered email, and 70+ integrations.