Free patient form templates | Coflow

New patient registration form: free patient intake template

Written by Coflow | Oct 30, 2026, 5:30:31 AM
Free template

Free digital patient registration form template

Use our free digital patient registration form for Australian practices, with Medicare, DVA, concession and health fund fields built in.

Reduce paperwork by sending it with Coflow. Patients receive a link to fill the form in before their appointment, and responses write back to your practice management system.

Send it digitally See template
Stored in Australia
No patient app or login
Collect e-signatures
Writes back to your PMS
new-patient-registration-form.pdfPage 1 of 2

New patient registration

Please complete this form before your first appointment. Your information is kept confidential.

Personal details
Title
MrMrsMsMissMxDr
Given name
Family name
Gender
FemaleMalePrefer not to say
Occupation
Pronouns
She / herHe / himThey / themShe / theyHe / theyAny pronouns
Are you of Aboriginal or Torres Strait Islander origin?
AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNeither Aboriginal nor Torres Strait IslanderPrefer not to say
Contact details
Email address
Mobile phone
Home phone
Residential address
Street address
Suburb
Postcode
State
ACTNSWNTQLDSATASVICWA
Medicare
Medicare number
Individual reference number (IRN)
Valid to
/
Page 1 of 2

New patient registration · continued

DVA card
Card colour
GoldWhiteOrange
Card number
Valid to
//
Concession card
Card type
Pensioner Concession CardHealth Care Card
Customer reference number (CRN)
Valid to
//
Private health insurance
Health fund
Member number
Member reference number
Valid to
/
Emergency contact
Name
Relationship
Phone
Page 2 of 2
9:41

Patient details

Preview only. Nothing you type is saved or sent.

Personal detailsPage 1 of 8
Personal details
Title
This field is required.
This field is required.
This field is required.
Gender
This field is required.
This field is required.
Pronouns
This field is required.
Are you of Aboriginal or Torres Strait Islander origin?
This field is required.
Contact details
This field is required.
This field is required.
This field is required.
Residential address
This field is required.
This field is required.
This field is required.
State
This field is required.
Medicare
This field is required.
This field is required.
This field is required.
DVA card
Card colour
This field is required.
This field is required.
This field is required.
Concession card
Card type
This field is required.
This field is required.
Valid to
This field is required.
Private health insurance
Health fund
This field is required.
This field is required.
This field is required.
This field is required.
Emergency contact
This field is required.
This field is required.
This field is required.

Form completed

When a patient submits it for real, their answers write back to their record in your practice management software.

Send it digitally

Send this form digitally

Patients fill it in and sign it on their phone or computer before they arrive, with no app or login. Coflow sends a reminder if they don’t finish, and their answers write back to your PMS.

  • Your logo, your fields
  • Automatic reminders
  • Writes back to your PMS
Book a demo

We’ll show you this form in Coflow and set it up with you.

PDF

Start with the free PDF

We’ll email you the printable form, plus a few ideas for moving it online when you’re ready.

Download the free PDF

On its way. Check your inbox, or download it now.

Download the PDF
Writes back to
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Learn more

Ready to send your forms digitally?

Book a demo and we’ll show you how Coflow sends forms by SMS or email, collects e-signatures and files answers into your practice management software.

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