Patient Intake Form Template
Personal details, insurance, symptoms, medications and allergies. Copy the HTML, add your Formclick access key, and every submission lands in your inbox — no backend required.
Customize Style
How to use this form
Sign up free and get your Formclick access key
Click "Copy HTML Code" above
Paste into your HTML and replace YOUR_ACCESS_KEY
Publish your page — submissions go to your inbox!
What's included
- 11 fields: Full name, Date of birth, Email, Phone, Insurance provider & member ID + 6 more
- Consent / agreement checkbox
- Posts to api.formclick.io — no backend needed
- botcheck honeypot spam protection
- Loading state & success message via formclick.min.js
- Responsive, accessible HTML & CSS
- Zero backend code needed
- Powered by Formclick API
Formclick perks
Fields included
- Full nameRequired
- Date of birthRequired
- EmailRequired
- PhoneRequired
- Insurance provider & member IDOptional
- Reason for visitRequired
- Current medicationsOptional
- AllergiesOptional
- Do you have any of these?Optional
- Emergency contact (name & phone)Required
- The information above is accurate to the best of my knowledge.Required
Frequently asked questions
How do I add this patient intake form to my website?
Copy the HTML (or download the file), replace YOUR_ACCESS_KEY with the key from your form's Connect tab in Formclick, and paste it into any page. It works on static sites, WordPress, Webflow, Shopify and every framework.
Where do the submissions go?
Every submission is saved in your Formclick dashboard and emailed to you within seconds. You can also forward them to Slack, Google Sheets, Telegram or a webhook.
Can I add or remove fields?
Yes. Any input with a name attribute is captured automatically — add, remove or rename fields freely. Keep the access_key, botcheck and from_name inputs and the script tag.
Do I need JavaScript?
No. The form submits as plain HTML. The formclick.min.js script is optional and adds no-reload submission, a loading state and your success message.