The crucial fields you need for a profitable patient intake form

There’s one tool almost every doc uses to create their patient intake forms.

They didn’t discover this tool in med school — though it certainly did help them get to graduation.

Most doctors use our trusty friend Google to help them design their patient intake forms.

They type ‘patient intake form’ into Google, find one that looks good, and use it to create a mock-up for their own form. And while this might be okay, it’s certainly not the best you can do.

Patient intake forms are basic but essential. They help you increase revenue retention and improve patient care. So they deserve more than a quick Google search.

A good patient intake form provides key information in three areas: who the patient is, why they are at the office, and how they’re going to

Part 1: Who they are

The first role of an effective patient intake form is to provide demographic and contact information for your patient. This helps you evaluate the patient, communicate with them, and gather relevant information for your billing department.

Make sure to include the following fields:

  • Name
    Some patients will go by a nickname (like “Billy”) but have a different legal name (like “William.”) Make sure you confirm that the name on the form is the name the insurance company has on file.
  • Date of birth
  • Sex
  • Address
    It’s more important to get the address the patient’s insurance company has on file. Keep in mind, this may or may not be their mailing address.
  • Social security number
    If you own a business where you have to collect money from people, socials are always important to have!
  • Contact info
    Ask for the most effective way to reach patients. In most cases, this will be email and cell phones. Include an area to opt-in for text message updates too, if your practice uses them.
  • Occupation/employer
    If a patient is injured at work and is pursuing compensation, you need to know where they work and what they do.
  • Emergency contact
    It’s never safe to assume the spouse is the emergency contact. Make sure to explicitly ask for this information. 
  • Make a copy of the patient’s driver’s license / ID card

How they’re going to pay

I recommend including this section directly below the demographic section on your form, because it’s so important. 

Be sure to gather:

  • Primary insurance details
  • Name of the subscriber
  • Subscriber’s date of birth
  • Guarantor
    Who is the person responsible for this patient’s care? In my family, my daughter is under her dad’s insurance policy, but I’m her custodial parent. I should be the one being contacted if there is a balance. Her father is the subscriber, but I am the guarantor. So you always want to ask for this information on your intake form.
  • Make a copy of insurance card(s) — primary, secondary, tertiary (if available)
    You don’t need to make patients fill out all their insurance information on the intake form. It’s probably only 5-10% of the time that practices look at the numbers on the intake forms when they need this information. They more often look at the copy of the card itself.

Why they’re at the office

This is the section where patient care comes into play. Knowing what to expect before walking into the exam room will help you as the provider offer more informed care, and the patient will feel better knowing you’re familiar with their case.

To do this, ask for the following information on patient intake forms:86523127-1024x682

  • Description of symptoms
    You’ll go deeper into this during the visit, but give the patient space to explain their symptoms on the form. Some offices use pain scales or charts where patients mark where they’re experiencing pain.
  • Medical history
    This helps you connect the dots if other family members have a similar issue. 
  • Allergy info
  • How did you find out about our practice?
    As a business (which all medical practices are!) it’s important to know where you patients come from. You should be feeding the channels that are working for you. For example, if you’re a primary doctor and your patient was referred by a specialist, you want to send a letter saying ‘Your patient was treated at our office, thanks for the referral! Please find attached your patient’s medical notes.’ It’s proper etiquette, completes the cycle, and helps with patient care. As a bonus, it also encourages that specialist to refer more patients your way.

One more thing to consider

I always recommend that practices include a basic disclaimer on their patient intake forms. You’ll need to work with the wording to properly match the laws of your state. But you essentially want to say:

The above information is true to the best of my knowledge. I authorize this office to bill my insurance company and I authorize my insurance company to pay my doctor directly. I know I am responsible for any balance.

This helps cross all the T’s and dot the I’s as far as collections are concerned.

Patient intake forms are an important part of your practice’s success. When you design them with efficiency in mind, they become a helpful tool for years to come.

On a scale of 1-10 (where 1 is poor and 10 is excellent,) how well is your patient intake form working? What fields are you missing on your current form? What other fields do you include that I didn’t list here?

We share more strategies like how to improve your patient intake forms in our free white paper. If you’re ready to increase your revenue and improve operations, click here to download 5 Strategies to Accelerate Cash Flow & Increase Profits.

Speak Your Mind


This site uses Akismet to reduce spam. Learn how your comment data is processed.