4+ New Patient Intake Forms – PDF

Hospitals deal with numbers of patients and guests every single day, which is why it is important to keep a documentation and record of each individual on the premises. One of the known documents is known as a new patient intake form. This is used along with other papers which are completed by a patient or the patient’s authorized relative. You may also see medical intake forms

New Patient Intake Form

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What Is a New Patient Intake Form?

A new patient intake form contains the medical history of a new patient and other relevant information that needs to be disclosed to the patient’s attending physician. Although it is necessary to acquire every bit of medical information from the patient, the time allotted for filling out the form must be lessened and must not take up too much from a staff’s service hours once it is processed. The disclosed data will be gathered to the management system of the hospital or clinic and will be kept as a record for the patient.

Examples of New Patient Intake Forms

There are several varieties of new patient intake forms, and these are as follows:

1. Family Practice New Patient Intake Form

This new patient intake form gathers the data of the patient which aids in determining whether the patient acquired his medical condition from someone in his family and relatives. Contents of the form include the patient’s reasons for visiting, the patient’s medical problems, current medications that are taken by the patient, family and social history, as well as the patient’s health habits. Sample medical questionnaires are also found on the form especially at the health habits section to determine the patient’s addiction issues, food intake, living will, preparedness, and overall safety. To identify the owner or user of the form, the patient’s name is indicated in the last area of the form.

Family Practice New Patient Intake Form

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2. Medical Pharmacy New Patient Intake Form

There are medical pharmacies that offer membership options for their clients and buyers. With this, they present medical pharmacy new patient intake forms to their buyers who are ones who take the medications that they purchase. The form contains the patient’s general information, a questionnaire that will determine if the patient will allow the pharmacy to deliver the prescribed medicine upon request, as well as the insurance and health information of the patient. Once the fields are completed, the patient or the buyer must affix his signature and submit the form to the pharmacy staff.

Medical Pharmacy New Patient Intake Form

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3. Neurology New Patient Intake Form

Curing disorders and concerns relating to an individual’s nerves and nervous system is the job of neurologists. These professionals use neurology new patient intake form to acquire the basic identification of their patient, as well as the name of the neurologists and the care provider of the patient. Other details to be disclosed in this type of patient intake form includes the patient’s medical history, allergy list, medications, family history, and the patient’s social history. By obtaining the patient’s details, a neurologist will be able to address the patient’s concerns and develop a medical plan to cure the patient’s illness. You may also check out mental health forms

Neurology New Patient Intake Form

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Sections to Include in a New Patient Intake Form

Even though there are readily made intake forms online that can be customized, it is always an advantage if hospitals and clinics will create their own new patient intake forms from scratch. With this, the significant sections to be included on the form are listed below to aid anyone who will begin creating their intake forms:

1. Patient information

This section must cater the patient’s full legal name, electronic mail address, contact information, age, residential address, and occupation. Most intake forms also have the patient’s choice of emergency contact whether he/she is his/her spouse, relative, and even a representative from the patient’s company. In addition, the name of the person who referred the hospital or clinic to the patient can also be indicated on the form to allow the hospital staff in sending a formal letter of gratitude in acknowledging the services that they offer to their clients.

2. Current medical complaints

This is where the patient will be able to disclose his medical issues along with its descriptions and the date when the incident occurred that escalated to the patient’s injury or medical-related problems. The list of the medical practitioners whom the patient had previously visited for a consultation is also indicated in this section as well as the activities that can trigger the illness. For an easier section that the patient can fill out, a medical questionnaire can be incorporated wherein the patient can indicate his answers immediately or in checkboxes.

3. Payment information

Hospitals and clinics who do not allow patient admissions before a payment is provided will need to include this section. Specifically, this centers on identifying the individual or party who will be providing the payment for the patient’s hospitalization and consultations. This section includes the name of the auto and health insurance where the patient is enrolled, and the insurance company’s contact information.

4. Medical history

Identifying if a patient has been treated under the same medical condition from the previous years is the purpose of having a medical history section. The patient’s last physical examination date, vitamins and supplements that are currently taken, and the patient’s medication allergies will also be disclosed to assure that the attending physician acknowledges the medical drugs present in the system of the patient. Other areas of the medical history include the patient’s pregnancy diagnosis, health habits, and family history. You may also like patient counseling forms

5. Care authorization

A care authorization is a type of medical authorization that is intended to be signed by the patient. This centers on allowing a medical establishment to provide care, treatment, and medication to the patient who is admitted. The authorization must also indicate to whom the X-ray films and medical-related photographs are given after it is printed out whether it will be to the patient or to the physician.

6. Acceptance agreement

This is essential for assuring that the patient is aware of the capacity of the medical staff to meet results and expected outcome. You may also see health assessment forms

7. Practice terms, conditions, and notices

In connection with the acceptance agreement, the medical establishment must indicate their policies or house rules to inform the patient about the dos and don’ts during his stay in the premises. The terms and conditions will state the regulations pertaining to the patient’s treatment procedures, billing statement and payments, healthcare operations, disclosure permission, and confidentiality of information to be used for the patient’s benefit. You may also check out nutrition assessment forms

8. Consent to treat

This section indicates the granted permission of the patient regarding the medical establishment’s intention to treat the patient. The patient’s signature along with the date of the day when he agreed to the terms of the medical establishment will complete the intake form. You may also see health inventory forms

New Patient Intake Paperwork Form

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The Importance of New Patient Intake Forms

New patient forms allow the medical staff to acquire the personal information of the patient which will be used to establish a medical report and record in their database. Additionally, the form is also an important tool that protects the hospital and clinic from liabilities and obligations since it contains general agreements and consent statements from the patient.

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