Patient Information Form

by  Raquel Shumway
Mar 17th, 2015 - Reviewed/Updated May 14th

We have two different samples for Patient Information Forms. We suggest that you review both and determine which best fits your practice model. Form #2 is editable so it could be easily modified for your organization. Both forms provide the basic information necessary for all types of healthcare practices.

Instructions for: Patient Information Form #1

Form #1 is a PDF file which does not include any insurance information and thus, it is best used in conjunction with the Insurance Information form.

The practice information at the top of the page is editable so be sure to modify it as necessary for your practice. 

CLICK HERE to download form #1.

Instructions for Patient Information Form #2:

Form #2 is a DOC file which does include some general insurance information, but it is not specific enough to properly determine insurance verification, therefore, it is best used in conjunction with the Insurance Information or Insurance Verification form(s).

This form is editable so it can be modified as necessary for your practice. For example, if you have billing software, make the fields on this form match up to the way that you would need to enter the information into your billing software. This not only speeds up and simplifies the process, it also reduces the likelihood of human entry errors.

CLICK HERE to download form #2.