A patient intake form collects what a clinic needs before a first visit: identity, contact details, the reason for the visit, and the emergency and coverage details staff use at check-in. It should not gather a full medical history, identifiers the front desk never uses, or card and bank numbers, because those belong in clinical or billing processes your practice has already approved. Have your clinical lead and counsel review the final questions before patients see them.
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A general intake is not a clinical history. Long lists of past conditions in an open form are hard to protect and rarely change a first visit. Let the clinician take the history in the room, or through the clinical process your practice has approved.
Most intake decisions do not need it. If billing requires a government identifier, collect it through the billing process your practice has approved and keep it out of general submissions and exports.
A general intake needs the patient's details and one emergency contact, not a household roster. Other people's details create privacy duties you have not planned for.
Card and bank numbers do not belong in a general intake. Use the billing process your front desk already runs, not a free-text box on a health form.
| Field | Type | Required | Why you ask it |
|---|---|---|---|
Full nameUse the name that appears on your identification. | Short text | Required | Matches the name staff search for, so the record is not split into two files. |
Preferred nameOptional. Tell us the name you like to be called. | Short text | Optional | Lets staff address the patient correctly. Leave it optional so people who do not use a preferred name are not asked to invent one. |
Date of birth | Date | Required | Confirms identity when two patients share a name, and dates the record for the clinician. |
Mobile phoneInclude the area code | Phone | Required | Lets the office call about a change to the visit or a question from the clinician. |
Email addressOptional. Leave this blank if you prefer phone calls. | Optional | Gives the office a second way to reach the patient if the phone number is wrong. | |
Reason for today's visitA short sentence is enough. Do not list test results or diagnoses here. | Long text | Required | Lets the clinician prepare. Ask for the main concern in the patient's own words, not a diagnosis. |
Emergency contactName someone who has agreed to be listed. | Section header | Starts the section that tells staff who to call if the patient cannot be reached. | |
Emergency contact name | Short text | Required | Lets staff reach a person the patient chose if they cannot reach the patient during a visit. |
Emergency contact phone | Phone | Required | The number staff actually call. A name without a number does not help the front desk. |
Health coverage carrierWrite the company name printed on the card. | Short text | Optional | Lets billing prepare the right claim. The member number belongs in the billing step, not in this general intake. |
Preferred pharmacyPharmacy name and town are enough. | Short text | Optional | Tells the clinician where to send a prescription if one is written at the visit. |
Privacy noticeI have read the practice's privacy notice | Multiple choice | Required | Records that the patient confirmed they read the practice's privacy notice. Use the wording your counsel has approved. |
Example only, not a real submission
Submissions appear in the form's grid. Name the person who reviews new entries before the first appointment of the day, and tell that person what to do when a field is blank or unclear.
Stored submissions wait for the scheduled job, which runs hourly in production. Once an entry has been processed, the form's creator receives a notice, so front-desk staff should check an early arrival directly rather than wait for that notice.
Owners can export submissions as CSV. Decide who may export, where the file is kept and when it is deleted, and follow your own records schedule.
Each submission can optionally create a Customer Care case with a priority, tags and assignees. Turn that on only if your front desk already works its queue in Customer Care; otherwise leave it off and use the grid.
A template is a list of questions to start from, not a finished form. Check each question against a decision your front desk or clinician makes, remove anything you cannot act on, and have your clinical lead approve the final set before patients see it.
Usually not in a general intake. Ask for the reason for the visit and the basics staff need at check-in, then take the detailed history during the visit or through the clinical process your practice has approved. That keeps sensitive details out of a general submission list.
That depends on your practice's policy and the consents it requires. A checkbox that confirms a privacy notice was read is different from a signed consent, which needs its own wording. Have your counsel approve any signed document before it is used.
Yes. The form is shared as a public link, so patients can open it on a phone or a computer. Keep the labels short, and test the form on a phone before you share the link.
Forms in Attain OS are shared as an online link, and there is no PDF or Word version to download. If the waiting room needs paper, print from your own process and treat the online version as the master copy.
Choose a category and a form type in the wizard. Answer three Atty Suggestions questions, then give the form a title. Atty builds the fields in the background. Edit the fields and ask Atty to refine them, then publish and share the /f/ link.
