Healthcare8 fields

Patient Intake Form

Collect patient information before their first visit.

Spam protectionEmail notificationsAI sales agentSubmission dashboardNo backend needed

Live Preview

Exactly what visitors will see on your site

Interactive

What you'll collect

Every field in this template, ready to use out of the box.

Full Name

text · required

Date of Birth

date · required

email · required

Phone

tel · required

Insurance Provider

text · optional

Current Medications

textarea · optional

Allergies

textarea · optional

Emergency Contact

text · required

Copy the Code

Choose HTML for static sites or React for component-based apps. Replace YOUR_FORM_ID with your Flowqen endpoint ID.

<form
  action="https://flowqen.com/api/f/YOUR_FORM_ID"
  method="POST"
  class="max-w-xl mx-auto rounded-[32px] border border-[#f0d9cf] bg-[linear-gradient(180deg,#fff7f2,#fffdfb)] px-6 py-7 shadow-[0_30px_90px_rgba(225,78,58,0.12)] sm:px-8"
>
  <h2 class="text-2xl font-semibold tracking-tight text-[#251c18] mb-6">Patient Intake Form</h2>

  <div class="space-y-4">
    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Full Name</label>
      <input type="text" name="fullName" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12" placeholder="John Doe" required />
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Date of Birth</label>
      <input type="date" name="dateOfBirth" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12" required />
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Email</label>
      <input type="email" name="email" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12" placeholder="patient@email.com" required />
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Phone</label>
      <input type="tel" name="phone" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12" placeholder="(555) 123-4567" required />
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Insurance Provider</label>
      <input type="text" name="insuranceProvider" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12" placeholder="Aetna, Blue Cross, etc." required />
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Current Medications</label>
      <textarea name="currentMedications" rows="4" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12 resize-none" placeholder="List all current medications..." required></textarea>
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Allergies</label>
      <textarea name="allergies" rows="4" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12 resize-none" placeholder="List any known allergies..." required></textarea>
    </div>

    <div>
      <label class="mb-1.5 block text-sm font-medium text-[#6b5548]">Emergency Contact</label>
      <input type="text" name="emergencyContact" class="w-full rounded-[20px] border border-[#efd8cf] bg-white px-4 py-3 text-sm text-[#2d201a] outline-none transition focus:border-[#E14E3A] focus:ring-4 focus:ring-[#E14E3A]/12" placeholder="Jane Doe — (555) 987-6543" required />
    </div>
  </div>

  <!-- Honeypot (spam protection) -->
  <div style="display:none">
    <input type="text" name="_gotcha" style="display:none" />
  </div>

  <button type="submit" class="mt-6 w-full rounded-[20px] bg-[#201814] py-3 text-sm font-semibold text-white transition hover:bg-[#382c26]">
    Submit
  </button>
</form>

What is a Patient Intake Form?

A comprehensive patient intake form for healthcare providers. Collects personal details, medical history, insurance information, and emergency contacts.