# Patient Intake Form Template > A calm two-step registration for a new patient: who they are and how to reach them, then their health history, current medication and reason for the visit, a consent to store their information and a signature. A Applications & intake template in the new Vonza Forms, “Patient intake”: A calm clinic intake: details, health history, consent and signature. ## What a patient intake form is for A patient intake form is the new-patient paperwork a practice used to hand over on a clipboard: personal details, contact information, health history, medication, the reason for the visit and the patient’s consent. Sending it before the appointment means the practitioner reads it ahead of time and the waiting room stays quiet. This template puts the personal details on the first step and the health questions on the second. Conditions are checkboxes with a “None of these” option, medication and the reason for the visit are open answers, and the form ends with a consent box worded for the clinic and a drawn signature. The thank-you screen reminds the patient to arrive ten minutes early. ### Who uses it - Physiotherapy, chiropractic and osteopathy clinics registering new patients. - Dental, optometry and private GP practices sending paperwork before a first visit. - Massage therapists, nutritionists and wellness practitioners taking a health history. - Fitness and rehabilitation studios that screen clients before training. ## What’s in the template Every question exactly as the template builds it, page by page. Change, add or remove any of them in the editor. Form title: “New patient registration — Willow Clinic”. Progress shows as steps. ### Page 1: About you - **Full name**: Name · required - **Date of birth**: Date · required - **Mobile**: Phone · required - **Email**: Email · required - **Home address**: Address · required ### Page 2: Your health - **Do you have any of these?**: Checkboxes · Asthma, Diabetes, Heart condition, High blood pressure, Allergies, None of these - **Current medication**: Long answer - **Reason for your visit**: Long answer · required - **I consent to Willow Clinic storing my health information to provide my care.**: Consent · required - **Signature**: Signature · required ### Button and thank-you screen - Submit button: “Register” - Thank-you screen: “You’re registered”, Thank you, {{name.first}}. Please arrive ten minutes before your first appointment. ## How to customise it A template is a starting point: every word, question and colour stays editable. - **Your clinic’s wording**: Rewrite the consent text and the conditions list for your practice and the questions your practitioners actually need. - **Show follow-ups only when needed**: Add a question such as “Tell us about your allergies” and a logic rule that shows it only when Allergies is ticked. - **Agreement and signature together**: Replace the consent box with an “Agreement & e-sign” block to show your full privacy notice or treatment terms, with “I agree” and a signature in one step. - **Keep it off search engines**: Turn on “Hide from search engines” in the form’s Link & SEO settings, and allow one response per person by email if patients should register once. ## What happens after someone submits The same Vonza Forms settings run behind every template. These are the ones this form uses. 1. **The response arrives in Responses**: Each response opens with every answer, the device and the time it took. Export all or some of them to CSV or Excel, or download one as a PDF. 2. **You and your team are told**: The email to you goes to you and up to five teammates on every response, with all the answers or a message you write, plus an in-app notification. 3. **The respondent becomes a CRM contact**: Everyone who leaves an email (here, “Email”) becomes a contact in your Vonza CRM, tagged with up to ten tags you choose. Existing contacts keep their details. 4. **They get a confirmation**: Turn on the email to the respondent, with your own subject and message, and attach their answers as a PDF. 5. **Automations and webhooks take over**: Use “Contact fills this form” in Automations to enrol people in a course, start an email sequence or add them to a list, or post each response to Zapier, Make or your own server with a webhook. Each registration opens in Responses with every answer; download it as a PDF for the patient’s file, and mark it Done once it has been read. For other intake paperwork, read more about Vonza [intake forms](https://vonza.net/intake-forms), or see the [Vonza form builder](https://vonza.net/forms) and [all 61 form templates](https://vonza.net/form-templates). - [appointment scheduling for your clinic](https://vonza.net/free-online-appointment-scheduling) ## More templates like this one - [Volunteer Sign-Up Form Template](https://vonza.net/form-templates/volunteer-sign-up-form): Fresh green cover with availability and interests. - [Coaching Application Form Template](https://vonza.net/form-templates/coaching-application-form): Bold black-and-yellow application for a personal training studio. - [Client Intake Form Template](https://vonza.net/form-templates/client-intake-form): Warm, editorial two-step intake for consultants and agencies. ## Frequently asked questions ### Can patients sign the intake form online? Yes. The template ends with a Signature block, where the patient draws their signature; it is saved privately with the response. You can also use an Agreement & e-sign block to show your terms first. ### Is the intake form suitable for medical records? Vonza makes no health-privacy certification claims, so check what the rules where you practise require before collecting health history online, and adjust the questions and consent text to match. ### Can I see a patient’s answers before the appointment? Yes. You can get an email on every new registration, and every response opens in Responses with the time it took, the device and a Download PDF button. ### Can patients fill it in on a phone? Yes. The form works on any screen, and the two steps keep each page short. Turn on “Let people continue later” and patients can save their answers and finish within 30 days.