About this template
Clinics use this form to register a patient before the visit: contact details, date of birth, emergency contact, medications, and a few measurements such as height and weight. Staff can read it before the appointment instead of starting from a blank clipboard.
One question asks for a payment preference. That is a note for the front desk, not a charge. Google Forms does not process cards. If you take payment, link to your own payment page from the description and delete any question you are not allowed to collect. Responses stay in a Google Sheet in the clinic's Drive. Edit the medication and history questions so they match how your practice actually charts.
Key features
- Collect complete patient demographics and emergency contact details in one submission.
- Track current medications and medical history securely before appointments.
- Standardize biometric data collection including height, weight, and date of birth.
- Mobile-friendly design allows patients to complete paperwork easily from any device.
- Automatically sync all incoming responses directly to Google Sheets for effortless tracking.
Use cases
New patient intake at medical clinics, dental offices, and wellness cā¦
New patient intake at medical clinics, dental offices, and wellness centers.
Initial registration for specialized therapy and counseling practices.
Pre-appointment screening and health history documentation.
Patient onboarding for physical therapy and rehabilitation clinics.
What this form collects
- Full Name (Short answer)Enter your first, middle, and last name as it appears on your government-issued ID.
- Email Address (Short answer)We will use this address to send appointment confirmations and care instructions.
- Contact Number (Short answer)Provide a phone number where we can reach you during business hours.
- Date of Birth (Date)Enter your birth date using the format MM/DD/YYYY.
- Sex Assigned at Birth (Multiple choice)Select the option that matches your medical record.
- Marital Status (Dropdown)Select your current marital status.
- Height (inches) (Short answer)Enter your height in total inches (e.g., 68 for 5'8").
- Weight (pounds) (Short answer)Enter your current weight in pounds.
- Home Address (Paragraph)Enter your street address, city, state, and ZIP code.
- Emergency Contact Full Name (Short answer)Provide the name of someone we can contact in case of an emergency.
- Relationship to Emergency Contact (Short answer)E.g., Spouse, Parent, Sibling, Friend.
- Emergency Contact Number (Short answer)Provide a reliable phone number for your emergency contact.
- Are you currently taking any medications? (Multiple choice)Include prescription drugs, over-the-counter medications, vitamins, and herbal supplements.
- Medication List and Dosages (Paragraph)If you answered yes above, please list the names and dosages of all medications you take.
- Payment Method (Multiple choice)Select how you plan to cover your consultation or service fee today.
FAQ
Does this form charge the patient?
No. The payment question records a preference. Google Forms does not charge cards. Take payment through your own system.
What does registration collect?
Name, contact details, date of birth, emergency contact, medications, height and weight, and a payment preference.
Can I remove clinical questions we do not use?
Yes. After the form is in your Drive, delete or rewrite any question that does not match your charting.
Where are the answers stored?
In the Google Sheet linked to the form, in your Google Drive. Treat that sheet like the rest of your patient records.
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.