Doctor and his nurse receptionist greet a patient as she signs in and provides health insurance info.

How to Improve Your New Patient Form

The form you use to gather information from your new patients has several uses:

1. Contact information.

Ask for work, home and mobile. Always get the new patient’s email address. Most importantly, ASK HOW THE PATIENT PREFERS TO BE CONTACTED. Some patients love text messages while others prefer email or calls to a specific number.

2. Insurance information.

Ask for secondary insurance, as well.

3. Questions about previous care.

Current problems, medical issues, etc. Anything you need to be aware of without bulking up the form with unncessary questions.

4. Agreement with legal and financial statements.

Be sure to include an agreement to be responsible for all costs not covered by insurance, consent to x-rays, acknowledgement of the “Notice of Privacy Practices” and so on.

5. Updates.

Include a space for patients to update their information at several subsequent visits.

How to Use Your New Patient Form to Generate New Patients

By adding a few extra questions to your New Patient Registration Form, you can track the results of your marketing efforts, thank those who recommend your practice and get patient referrals.

For example, you ask all new patients how they learned about your practice. If they were referred, who was the person? You must then thank this person!

Did they find you by searching the internet? Was your Yelp page helpful? Have they visited your website? If so, your web presence is an asset that may be worth investing more into. For example, if you pay $500 per month for your web presence and it generates 10 new patients per month, you have a goldmine! In theory, you can simply increase your web presence budget and see the same result ($1,000 = 20 new patients, $2,000 = 40 new patients, etc.).

Another great question to include on your intake form: “Do you have any friends or family members who may need dental (or medical/optometric) care?” Someone must then follow up to ensure the friends or family members are invited to come in.

New Patient Registration Sample Form

You can get a copy of a sample New Patient form by completing the form below. This sample form includes all of the questions described in this article.

You will have the choice of a medical or a dental version in either PDF or Word doc format. The download includes dozens of additional questions and legal statements for you to consider.

After you download the form, replace the ExecTech logo with your practice logo, customize the questions to fit your practice, save it and print out copies for your staff to start using immediately.

If your New Patient Form is already digital, simply copy and paste any of the questions you like.

* Practice Owner Name
Your Name (if different)..
Practice Name
Type of Doctor
* Office Phone
E-mail Address
Nearest ExecTech Office..
Please contact me regarding my practice