Patient Registration Form Template

Welcome to St. Beardyman's Hospital Please complete this registration formWhat is your *full name*?As it appears on your birth certificate or medical records.What is your email address?We'll use this to keep you up to date with appointments and news.What's your gender?

Male, Female, Non-binary/third gender, I prefer not to answer

Which year were you born in?In which month of {{field:68882e916333c08d}} were you born?

January, February, March, April, May, June, July, August, September, October, November, December

On which day of {{field:ed7d0417bd8ee543}} {{field:68882e916333c08d}} were you born?Please upload a picture of yourself for our records.We accept images in .png and .jpg formats.Do you have health insurance?You may be covered by your workplace or a family member.

Yes, No

Are you the health insurance policy holder?

Yes, No

What is the *full name* of the health insurance policy holder?As it appears on the heath insurance policy certificate.What is the name of your health insurance company?What is your health insurance policy number?What is the street address of your insurance company?What is their city and state?What is their postal or zip code?Please upload a copy of your medical insurance documents.We'll check the details you provided against this document.*Thank you for sharing your personal and health insurance details.*\* \*We now just need to ask you a few more questions for our medical records.What is your blood type?

A+, A-, B+, B-, AB+, AB-, O+, O-

Do you have any allergies?

Yes, No

What are you allergic to?Be careful to list all allergies, including any allergies to medication.Are you taking any medications currently?

Yes, No

Which medications are you currently taking?Be careful to list all of them.Are you currently pregnant or is there a chance you could be?If you are unsure, please ask your health professional about a free pregnancy test.

Yes, No

How frequently do you consume alcohol?Please be honest.How frequently do you smoke?Please be honest.Please enter the contact details of someone you trust.We will contact this person in case of an emergency.

What is the *full name* of your emergency contact?

What is your relationship with this person?

What is their phone number?

*Please confirm the following details.*\* Full name: \*{{field:6860204f1de99c1e}} *Email:* {{field:aa46bb44a37398a1}}\* Gender: \*{{field:6fb3d2c5058ccb3f}} *Date of birth:* {{field:ed7d0417bd8ee543}} {{field:01fe2c007320b9b6}}, {{field:68882e916333c08d}} *Blood type:* {{field:cc6df01a4ab75f1a}} *Health Insurance Provider:* {{field:d13c9fe4efb7351e}} *Health Insurance Policy Number:* {{field:12a360febe11fd25}} *Emergency contact:* {{field:df7518d68b772818}} *Emergency phone number:* {{field:b8858dfa03f184eb}}*Please confirm the following details.*\* Full name: \*{{field:6860204f1de99c1e}} *Email:* {{field:aa46bb44a37398a1}}\* Gender: \*{{field:6fb3d2c5058ccb3f}} *Date of birth:* {{field:ed7d0417bd8ee543}} {{field:01fe2c007320b9b6}}, {{field:68882e916333c08d}} *Blood type:* {{field:cc6df01a4ab75f1a}} *Health Insurance Provider:* N/A *Health Insurance Policy Number:* N/A *Emergency contact:* {{field:df7518d68b772818}} *Emergency phone number:* {{field:b8858dfa03f184eb}}*Thank you.* Your patient registration profile has been submitted successfully.

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Why waste time preparing, printing and organizing paperwork? Save time with a digital patient registration form. Collect your patients’ info in one step, and let our integrations organize your data. This means less work for staff, and shorter wait times for patients.

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Patient registration form FAQs:

An online registration form helps you save time, boost productivity and keep patients happy. Send patients a link to the form when they arrive, and they can fill it out in the waiting room before their appointment. And thanks to our smart integrations, all your patients’ info can be directed to a spreadsheet where it’ll organize automatically.

No more sifting through piles of pages or manually importing data. With a typeform, you can significantly reduce paperwork and patient wait time—better for your staff, better for patients and better for the planet.

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.