About this template
Streamlining patient intake is essential for any modern healthcare practice or wellness clinic. This comprehensive Square Registration Form template helps medical providers, therapists, and wellness practitioners collect critical patient information, contact details, emergency contacts, and current medication history before the first appointment.
Designed to reduce front-desk bottlenecks and minimize manual data entry, this form replaces cumbersome paper clipboards with a clean, digital intake workflow. Patients can securely submit their personal information, biometric details like height and weight, and insurance or payment preferences directly from their mobile devices or computers. By gathering accurate medical background and contact information upfront, clinical staff can prepare thoroughly and ensure a seamless, patient-centered experience from the moment someone books a visit.
Doc2Form makes it easy to deploy this template directly to Google Forms in seconds. Customize fields, adjust questions to match your practice guidelines, and instantly manage submissions in Google Sheets without dealing with complex software or migration hassles.
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
How do I use this template with Doc2Form?
Simply click to convert or import this template, and Doc2Form will automatically generate a fully editable Google Form in your Google Drive account.
Can I customize the questions on this registration form?
Yes! Once the form is created in your Google account, you have complete control to add, remove, or edit any questions using the standard Google Forms editor.
Where are patient submissions stored?
All form responses are saved securely in your Google Drive and can be linked to a Google Sheets spreadsheet for instant review and organization.
Is this registration form mobile-friendly?
Yes. Google Forms automatically optimize layouts for smartphones, tablets, and desktop computers so patients can fill out paperwork anywhere.
Can I collect payments through this form?
While Google Forms handles core data collection, you can easily include payment links or instructions within the form description, or pair it with your preferred checkout workflow.
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.