Patient Intake Form Template

What is in the Patient Intake Form template?

The Patient Intake Form template holds 8 questions, 5 of which must be answered before it can be submitted and 3 of which are optional. Between them they capture short typed answers, a date, an email address, a phone number, multi-select answers and longer written comments.

Broken down by field type, the Patient Intake survey is 2 comment boxes, 2 contact fields, 2 text fields and 1 choice questions.

The 1 choice question in the Patient Intake survey between them offer 5 preset answers, and every one of those labels is editable — the wording listed below is a starting point, not a fixed list.

When should you use the Patient Intake Form template?

The Patient Intake Form is filed under “Healthcare”, “Intake” and “Patient”, in the Healthcare & Medical part of the library, where it is aimed at teams standardising something people were doing on paper. Collect essential patient information before an appointment.

Surveys get answered wherever the respondent already is — a link in an email, a QR code on a receipt, a tablet handed across a counter, or a kiosk-locked device left on a stand. At 8 questions, only 5 of them required, the Patient Intake survey is short enough to finish in one sitting, which is what keeps completion rates up.

Does the Patient Intake Form work offline?

Yes. Once the Patient Intake Form is published, the 8 fields and every answer option are stored on the device, so the survey opens and completes with no connection at all. Each response is written to the device first and queued; when signal returns it syncs on its own, keeping the time it was actually captured rather than the time it uploaded.

Because all 8 fields in the Patient Intake Form are text and choice inputs, a queued response is tiny and syncs the moment any connection appears — a shared hotspot is plenty. Kiosk mode locks a tablet to this survey alone, so the next person cannot wander into anything else.

How do you customise the Patient Intake Form template?

Open the Patient Intake survey in the builder and all 8 questions land as editable fields — nothing is locked to the template. Rewrite the wording, drag fields into a different order, flip any of the 5 required fields to optional (or the other way round), and add anything missing from the 20+ field types in the builder.

The Patient Intake survey's 5 preset answers are the fastest thing to make your own: swap in your own product names, sites or departments and it reads as if you wrote it from scratch.

The Patient Intake Form runs on a single screen as it stands. Add a page break to split its 8 fields across several, or conditional logic to hide fields that an earlier answer has made irrelevant.

Nothing about the Patient Intake Form stays Survtapp-branded, either: your logo, your colours and your own URL slug replace ours, so the 8 fields you publish read as part of your own site rather than as a template someone downloaded.

What happens to the responses you collect?

Every response from the Patient Intake survey lands in one place with its timestamp, the agent who collected it and, where the device allows, where it was captured. From there each of the 1 choice question gets a bar or pie breakdown and written comments are listed in full rather than summarised away.

Export the lot to CSV, Excel, JSON or PDF whenever you want it elsewhere, or set a trigger so a response from the Patient Intake Form emails the right person the moment it arrives. Data is held in Canada, the responses stay yours, and you can export or delete them at any time.