New Patient Phone Call Intake Form

A one-page intake form for new patient phone calls. It captures patient information such as name, date of birth, phone, address, email, and gender, plus insurance details like subscriber, provider, member ID, policy and group numbers, and employer. It also records the reason for the visit, history notes like the last visit, last x-rays, latex allergy, and whether the patient is nervous, the preferred day and time, and how the patient found the office.

Keep it next to the phone so whoever answers takes the same information on every call. The front desk can then verify insurance before the visit and enter the details into the practice management system, and the referral source line shows where new patients come from.