# Patient Intake Template
> Patient Intake template for WordPress with 10 fields. One-click install with FormForge Pro plugin. New patient registration and medical history.
- Canonical:
- Last updated: 2026-03-15
- HTML version:
---
Agency
10 fields
Industry-Specific
New patient registration and medical history.
### Personal Information
Full Name \*
Date of Birth \*
Gender Select...MaleFemaleOtherPrefer not to say
Email Address \*
Phone Number \*
### Insurance Information
Insurance Provider
Policy Number
### Medical History
Known Allergies
Current Medications
Pre-existing Conditions
Diabetes Hypertension Heart Disease Asthma None
## Form Fields
| Field | Type | Required |
| --- | --- | --- |
| Full Name | Text | Required |
| Date of Birth | Date | Required |
| Gender | Select | Optional |
| Email Address | Email | Required |
| Phone Number | Tel | Required |
| Insurance Provider | Text | Optional |
| Policy Number | Text | Optional |
| Known Allergies | Textarea | Optional |
| Current Medications | Textarea | Optional |
| Pre-existing Conditions | Checkbox | Optional |
## What’s Included with Agency
Everything in Business, plus:
Industry-Specific Templates
White-Label Branding
Priority Support
Unlimited Sites
Client Management Tools
Custom Integrations
1 Year Updates & Support
## Related Templates
Patient Name \*
Date of Birth \*
Phone Number \*
Preferred Provider Select...Any availableDr. SmithDr. Jones
Reason for Visit \*Select...Annual Check-upSick VisitFollow-upNew Concern
Urgency
Routine Within a few days Urgent (today/tomorrow)
Preferred Date
Describe Your Symptoms
Agency
8 fields
### Medical Appointment Request
Patient appointment scheduling with reason for visit.
[View Template](https://royalplugins.com/formforge/templates/appointment-request-medical/)
Student Name \*
Student ID \*
Course \*Select...Course ACourse BCourse C
Assignment Title \*
Upload Assignment \*
Click or drag to upload
Comments for Instructor
Agency
6 fields
### Assignment Submission
Students submit assignments/homework online.
[View Template](https://royalplugins.com/formforge/templates/assignment-submission/)
Full Name \*
Email Address \*
Phone Number \*
Type of Case \*Select...Personal InjuryFamily LawCriminal DefenseEmployment LawReal EstateOther
Date of Incident (if applicable)
Describe Your Situation \*
Desired Outcome
Agency
7 fields
### Case Evaluation Request
Request a free case evaluation.
[View Template](https://royalplugins.com/formforge/templates/case-evaluation/)
## Use This Template
Get FormForge Agency and start building with the Patient Intake template today.
[Get FormForge Agency](https://my.royalplugins.com/checkout/?add-to-cart=248)