Collect Comprehensive Client Information Before First Appointment

What You Get

This client intake template collects complete information before first appointments. Fifteen pre-configured fields capture contact details, demographics, emergency contacts, medical history, current medications, allergies, visit reason, and consent documentation. Suitable for healthcare, wellness, therapy, and professional service providers requiring detailed client records.

Template Structure

First Name (Required)

Text input for client's first name. Character limit 2-50 characters. Required for client records and appointment scheduling.

Last Name (Required)

Text input for client's last name. Character limit 2-50 characters. Required for formal documentation and billing.

Email Address (Required)

Email field with validation. Required for appointment confirmations, intake follow-up, and client communication. Validated format ensures deliverability.

Phone Number (Required)

Phone field for appointment reminders and urgent contact. Required for day-of coordination and emergency situations.

Date of Birth (Required)

Date picker for age verification and client records. Required for medical dosing calculations, age-appropriate treatment, and insurance processing. Used to calculate age automatically.

Address (Required)

Text input for client's address. Character limit 10-200 characters. Required for client records, emergency contact, and billing/insurance purposes.

Emergency Contact Name (Required)

Text input for emergency contact person. Character limit 2-100 characters. Required safety protocol for medical, dental, therapy, or physical services. Who to call if client has medical emergency during appointment.

Emergency Contact Phone (Required)

Phone field for emergency contact number. Required to reach emergency contact if needed during treatment or medical situation.

How Did You Hear About Us? (Optional)

Dropdown menu for referral tracking. Default options:

• Google Search
• Social Media
• Referral
• Advertisement
• Other

Optional field tracks patient acquisition channels. Customize with your marketing channels (insurance directory, doctor referral, Yelp, etc.). Valuable for ROI analysis but not essential for treatment.

Reason for Visit (Required)

Text area for consultation purpose. Character limit 10-1000 characters. Required minimum 10 characters ensures clients explain their needs. Helps provider prepare for appointment. "Back pain for 3 weeks" is more useful than "checkup."

Current Medications (Optional)

Text area for medication list. Character limit maximum 1000 characters. Optional to reduce friction, but critical for medical safety (drug interactions). Help text: "List any medications you're currently taking (or write 'None')." Clients comfortable sharing will list medications.

Allergies (Optional)

Text area for allergy information. Character limit maximum 500 characters. Optional but important for medical safety. Help text: "List any allergies (medications, foods, etc.) or write 'None'." Providers ask verbally if left blank.

Medical History (Optional)

Text area for health background. Character limit maximum 2000 characters. Optional due to privacy sensitivity. Help text: "Any relevant medical conditions, surgeries, or ongoing treatments..." Clients share what's relevant to current visit.

Treatment Consent (Required)

Checkbox field for consent documentation. Single option: "I consent to treatment and understand the privacy policy."

Required for legal compliance. Link to privacy policy in checkbox label. Clients must acknowledge before submitting intake.

Communication Preferences (Optional)

Checkbox field for communication authorization. Single option: "I authorize communication via email and text for appointment reminders."

Optional HIPAA consideration. Clients opt into digital communication; those concerned about privacy leave unchecked (call-only communication).

How to Use This Template

1. Load Template

Click "Use This Template" and sign up for FormFlux (free, no credit card). Client intake form loads in the builder with all fields pre-configured.

2. Customize for Your Practice Type

Adjust fields based on specialty:

For Medical Practices

• Add: Insurance Provider, Policy Number, Primary Care Physician
• Add: Pharmacy name and phone
• Medical History: More specific (diabetes, heart disease, cancer history)

For Dental Practices

• Remove: Current Medications (unless doing procedures)
• Add: Last dental visit date, Current dental concerns
• Add: X-ray consent checkbox

For Therapy/Counseling

• Remove: Allergies (not medically relevant)
• Add: Previous therapy experience (Yes/No + details)
• Add: What are your goals for therapy? (text area)
• Reason for Visit → What brings you in today?

For Wellness/Spa Services

• Make medical fields optional or remove entirely
• Add: Skin type, Skincare concerns
• Add: Areas of focus for massage
• Remove: Insurance fields

For Legal Services

• Remove: Medical History, Medications, Allergies
• Add: Case type (dropdown), Opposing party information
• Add: Desired outcome (text area)
• Reason for Visit → Legal matter description

3. Add Insurance Fields (If Applicable)

For practices billing insurance:

Insurance Information

• Type: Text fields
• Labels: "Insurance Provider," "Policy/Member ID," "Group Number"
• Required: Optional (some pay cash)
• Place after: Address field

Primary Care Physician

• Type: Text field
• Label: "Primary Care Physician Name"
• Required: Optional
• Use case: Coordination of care, referral verification

4. Set Up Intake Processing Workflow

Handle new client forms:

Before First Appointment

1. Send intake form link in appointment confirmation email

2. Request completion 48 hours before appointment

3. Review submissions 24 hours before appointment

4. Flag concerns (allergies, complex medical history) for provider

Day of Appointment

1. Verify intake was completed (check Google Sheet export)

2. If not completed: Have client fill out paper form on arrival (15 min early)

3. Provider reviews intake before entering exam room

After Appointment

1. Transfer intake data to EMR/practice management system

2. Mark Status: "Transferred to EMR"

3. Archive FormFlux submission for compliance

5. Configure Confirmation Email

Confirm intake receipt:

1. Enable auto-reply

2. Subject: "New Patient Intake Received"

3. Message:

```

Hi {{first_name}},

Thank you for completing your intake! We've received your information and look forward to your first appointment.

Next Steps:

- We'll review your intake before your appointment

- Bring your insurance card and photo ID (if applicable)

- Arrive 10 minutes early for check-in

- Bring list of current medications (if not provided)

Your Appointment:

- Date: [Appointment date from booking]

- Time: [Appointment time]

- Location: [Address or video link]

Need to update information? Reply to this email.

See you soon!

[Practice Name]

[Phone Number]

```

6. Handle HIPAA Compliance

For covered entities:

HIPAA Considerations

• FormFlux is NOT HIPAA-compliant without BAA
• Alternative 1: Use HIPAA-compliant form tool (JotForm HIPAA, FormAssembly)
• Alternative 2: Collect intake via secure patient portal
• Alternative 3: Paper forms in office

For Non-Covered Entities (Wellness, Coaching)

• FormFlux works fine (not handling PHI under HIPAA)
• Still maintain data security best practices
• Include privacy policy link in consent checkbox

7. Create New vs Returning Patient Workflows

Different intake needs:

New Patients (Full Intake)

• Send this detailed 15-field intake form
• Review before appointment
• Extra time allocation (first visits take longer)

Returning Patients (Update Form)

• Create simplified update form (3 fields only):

- Has anything changed since last visit? (Yes/No)

- If Yes: What changed? (text area)

- Current medications (update)

• Send annually or before significant procedures

Customization Examples

Add Photo Upload

For visual documentation:

• Type: File upload
• Label: "Upload photo of insurance card (front and back)"
• Required: Optional
• Use case: Insurance verification, billing

Add Signature Field

For legal consent:

• Type: Signature field (Pro feature)
• Label: "Patient/Client Signature"
• Required: Yes
• Use case: Treatment consent, HIPAA authorization

Add Responsible Party Information

For billing purposes:

• Type: Text fields
• Labels: "Responsible Party Name," "Relationship to Patient," "Responsible Party Phone"
• Required: Optional
• Use case: Different billing contact than patient

Add Appointment Preparation

Help clients prepare:

• Type: Checkbox
• Label: "Please bring to your appointment"
• Options: Insurance card, Photo ID, List of medications, Previous medical records
• Required: No (informational only)
• Use case: Reduce forgotten items

Ready to Use This Template?

Click "Use This Template" to load the client intake form in your FormFlux account. Free signup, no credit card required. Customize for your practice type, set up intake workflow, and start collecting detailed client information.

What's included:

• 15 pre-configured fields
• Medical history collection
• Emergency contact fields
• Allergy and medication tracking
• Treatment consent documentation
• Email validation
• Mobile-responsive design
• Conversational mode
• All integrations available
• Export to CSV/JSON

Setup time: 3-4 minutes Cost: Free (Pro features optional) No credit card required HIPAA Note: For covered entities, ensure HIPAA compliance via BAA or use dedicated healthcare intake software.