About this template
A Contact Information Request Form is essential for medical practices, clinics, and healthcare providers who need to securely and accurately gather patient contact details before an appointment or admission. This form standardizes the collection of home, work, and cell phone numbers, physical addresses, email addresses, and designated emergency contact information.
By streamlining this intake workflow digitally, clinics eliminate the errors and legibility issues associated with traditional paper forms. Staff members can quickly review incoming submissions, verify patient data, and update practice management systems with confidence. Whether you are onboarding new patients or updating records for existing ones, this template saves valuable administrative time.
Doc2Form makes it effortless to deploy and customize this template for your practice. Share the link via email or embed it on your website to ensure patients can submit their information seamlessly from any device before arriving.
Key features
- Capture complete phone, email, and mailing address details instantly.
- Designate preferred communication channels for streamlined outreach.
- Collect mandatory emergency contact details for patient safety.
- Fully optimized for mobile devices so patients can fill it out on the go.
- Instantly sync responses to your practice databases and spreadsheets.
Use cases
- New patient registration for medical and dental clinics.
- Updating contact records for existing healthcare practice clients.
- Telehealth intake information collection prior to virtual consultations.
- Emergency contact verification for outpatient procedures.
What this form collects
- Full Name (Short answer)Enter your first, middle, and last name as it appears on your official ID.
- Email Address (Short answer)Enter the email address where we can send appointment reminders and care updates.
- Cell Phone Number (Short answer)Enter your primary mobile number for calls or text notifications.
- Home Phone Number (Short answer)Optional: Enter your landline or alternative home number.
- Work Phone Number (Short answer)Optional: Enter your office or work extension number.
- Preferred Phone Number (Multiple choice)Which phone number should we use when we need to reach you during the day?
- Residential Address (Paragraph)Enter your street address, apartment or suite number, city, state, and ZIP code.
- Emergency Contact Full Name (Short answer)Enter the full name of the person we should contact in case of an emergency.
- Emergency Contact Relationship (Short answer)Specify your relationship to the emergency contact (e.g., Spouse, Parent, Sibling).
- Emergency Contact Phone Number (Short answer)Enter the primary phone number for your emergency contact.
FAQ
What is a Contact Information Request Form?
It is a digital intake form used by healthcare providers and organizations to gather accurate contact details, addresses, and emergency contacts from potential or existing patients.
How do patients access and fill out this form?
You can share the form via a direct link in appointment confirmation emails, text messages, or embed it directly on your practice website.
Can I customize the fields in this template?
Yes! Once you bring this template into Google Forms via Doc2Form, you can easily add, remove, or modify any questions to fit your specific practice requirements.
Where are the submitted contact details stored?
All responses are securely saved in a connected Google Sheets spreadsheet, giving you an organized database of patient contact information.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.