About this template
The Hospital Admission Form is a critical tool for medical facilities to standardize the patient intake process. By moving away from paper-based systems, hospitals and clinics can ensure that essential patient demographics, insurance details, and medical history are captured accurately and securely before the patient reaches the examination room.
This template is designed to be user-friendly for patients while providing administrative staff with structured data that can be easily reviewed. It covers everything from basic contact information and emergency contacts to specific procedure details and legal consent. Using Doc2Form to deploy this as a Google Form allows your team to centralize incoming data, minimize transcription errors, and ensure that every patient record is complete and ready for the medical team upon arrival.
Key features
- Standardize patient data collection for faster check-ins.
- Capture emergency contact details and insurance information.
- Include mandatory consent and authorization sections.
- Responsive design for use on tablets in waiting areas.
- Automated data collection directly into Google Sheets.
Use cases
- Routine hospital inpatient admissions.
- Outpatient surgery registration and scheduling.
- Emergency department patient intake.
- Specialized clinic patient onboarding.
What this form collects
- Patient Full Name (Short answer)Enter your full legal name.
- Date of Birth (Date)Please enter your date of birth (MM/DD/YYYY).
- Gender (Multiple choice)Select your gender identity.
- Admission Date (Date)The date you are scheduled for admission.
- Planned Procedure (Paragraph)Briefly describe the procedure you are being admitted for.
- Emergency Contact Name (Short answer)Name of the person we should contact in case of an emergency.
- Relationship to Patient (Short answer)E.g., Spouse, Parent, Sibling.
- Emergency Contact Phone (Short answer)Best phone number to reach your emergency contact.
- Consent and Authorization (Checkboxes)By checking this box, you authorize the hospital to perform the necessary medical procedures and acknowledge that you have provided accurate information.
- Patient Signature (Short answer)Please type your full name here to serve as your digital signature.
FAQ
Why use a digital form for hospital admissions?
Digital forms reduce manual data entry, improve the accuracy of patient records, and allow for faster processing times during the busy admission phase.
Can I customize this form for my specific clinic?
Yes. Once you load this template into Doc2Form, you can add, remove, or reorder fields to match your facility's specific intake requirements.
How do I ensure patient information is secure?
By using Google Forms, your data is protected by Google's enterprise-grade security. Ensure you have the appropriate organizational settings enabled to maintain compliance with your local healthcare data regulations.
Can patients fill this out on their own devices?
Absolutely. You can share the form link via email, SMS, or a QR code displayed at your reception desk, allowing patients to complete their intake on their own smartphones or tablets.
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.