New patient intake form template
Medical history before the first visit. It asks for name, date of birth, email and phone, plus 30 more questions. Use this free form template as it is, or change any question, the style and the thank-you screen, then share it or put it on your site.
Styles
One form, 18 looks.
Pick one, or bring your color.
Customize in minutes
Make it yours.
No code.
Change any question, add your own from 26 question types, and show each one only when it matters.
- Short text
- Long text
- Phone
- Website
- Number
- Money
- Pick one
- Pick many
- Dropdown
- Yes or no
- Checkbox
- Stars
- NPS 0–10
- Opinion scale
- Ranking
- Matrix
- Date
- Time
- Date range
- Full name
- Address
- File upload
- Signature
- Statement
- Hidden
Show-if logic
Ask the next question only when an earlier answer calls for it.
Pages and progress
Split long forms into pages with a progress bar.
Scores and results
Turn answers into a score and show each person what it means.
Files and signatures
Take uploads up to 10 MB and signatures drawn on any screen.
Booking
Open your calendar on the thank-you screen, with name and email filled in.
Consent by region
An opt-in box where the law asks for one, a short notice everywhere else.
Every answer a contact
The company comes from the work email, the campaign from the link.
Spam stays out
A hidden trap, rate limits and temporary emails refused.
Connect to any app
Answers go where you work.
Live in a minute.
- 01
Use the form template
It opens in Claritia ready to go, in the style you picked. Answers are linked to your contact fields and the form goes live.
- 02
Connect your tools
Send answers to HubSpot, Salesforce or Omniscient, open your calendar after a booking form, and tell your team in Slack.
- 03
Share it anywhere
Send the link, or add one line to Webflow, WordPress, Framer or any page. Every answer lands as a contact.
Frequently asked questions
Something else? hello@tryclaritia.com
Can I customize the new patient intake form?
Yes. Add, remove and reorder questions, change the wording and options, and set which ones are required. Pick one of 18 styles or your own color. Tailor can also rewrite the wording for your business from one sentence.
What does the new patient intake form collect?
It asks for name, date of birth, email, phone, address and emergency contact name, plus 28 more questions. You can add or remove any of them.
Is the new patient intake form mobile-friendly?
Yes. Every form fits phones, tablets and computers, and works with a keyboard and screen readers.
Is the new patient intake form template free?
Yes. Every form template is free on every plan, including the free one. Use it, change it and share it as often as you like.
Where do the answers go?
Each answer is saved in Claritia with the page and campaign the visitor came from. From there it can sync to HubSpot, Salesforce or Omniscient.
How do I put it on my website?
Share the link, or paste one line of code where the form should show. It fits any website, including Webflow, WordPress, Framer and plain HTML.
Can it collect health information?
This form asks for health details, so it stays a draft until your workspace confirms a signed business associate agreement (BAA) with us.
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