Free Tool

Patient Intake Form Generator

Build a professional patient intake form in minutes. Choose a template, customize fields, and export clean HTML — completely free.

Step 1

Choose your practice type

Start with a pre-built template designed for your specialty.

Step 2

Customize your form

Add, remove, or modify fields. Toggle required status. Preview in real-time.

Practice Name

Patient Information

Full Name

Text

Date of Birth

Date

Gender

Dropdown

Phone Number

Phone

Email Address

Home Address

Text

Emergency Contact Name

Text

Emergency Contact Phone

Phone

Insurance Information

Insurance Provider

Text

Policy/Member ID

Text

Group Number

Text

Subscriber Name

Text

Subscriber Date of Birth

Date

Relationship to Subscriber

Dropdown

Medical History

Are you currently under a physician's care?

Yes / No

List current medications

Long Text

Do you have any drug allergies?

Yes / No

If yes, please list allergies

Long Text

Heart disease or high blood pressure?

Yes / No

Diabetes?

Yes / No

Bleeding disorders?

Yes / No

Are you pregnant?

Yes / No

Dental History

Reason for today's visit

Text

Date of last dental visit

Date

Previous dentist name

Text

Do you experience dental anxiety?

Dropdown

Do you grind or clench your teeth?

Yes / No

Sunny Dental Care

New Patient Intake Form

Patient Information

Full Name *

Date of Birth *

Gender

Phone Number *

Email Address *

Home Address *

Emergency Contact Name *

Emergency Contact Phone *

Insurance Information

Insurance Provider *

Policy/Member ID *

Group Number

Subscriber Name *

Subscriber Date of Birth

Relationship to Subscriber *

Medical History

Are you currently under a physician's care? *

Yes

List current medications

Do you have any drug allergies? *

Yes

If yes, please list allergies

Heart disease or high blood pressure? *

Yes

Diabetes? *

Yes

Bleeding disorders? *

Yes

Are you pregnant?

Yes

Dental History

Reason for today's visit *

Date of last dental visit

Previous dentist name

Do you experience dental anxiety?

Do you grind or clench your teeth?

Yes

Frequently Asked Questions

Absolutely. You can add, remove, and reorder fields, change field types, toggle required status, and rename sections. The generator gives you a starting template that you can fully customize before exporting.

The form is exported as clean, formatted HTML that you can copy and paste. You can use this in your website, email it to patients, or print it as a paper form. The HTML is responsive and works on mobile devices.

The form template itself is designed with HIPAA best practices in mind (minimal data collection, consent sections). However, HIPAA compliance also depends on how you host and transmit the form. For fully HIPAA-compliant digital intake, FrontDesk provides encrypted, secure patient intake forms built-in.

The exported HTML can be hosted on your website, but for a complete digital intake solution with e-signatures, secure storage, and EHR integration, consider FrontDesk's built-in patient intake system.

Digital intake reduces check-in time by 10-15 minutes per patient, eliminates transcription errors, improves data accuracy, and creates a better first impression. Practices using digital intake report 30% fewer incomplete forms and significantly faster front desk workflows.

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Go digital with patient intake

FrontDesk sends secure digital intake forms automatically before each appointment — no paper, no data entry.

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