Hospital Admission Form

The hospital admission form is designed to collect basic information about patients who are about to be admitted.
Get This Form Template How to add Hospital Admission Form in your website?

Doctor Details

*Only to be filled in by hospital administration

Patient Information


Purpose of Visit

You will undergo further assessment by the doctor
Please list them

Guardian Information/Emergency Contact


Agreement

Hospital Admission Form

What you’ll love about this form

  • Totally customizable
  • Integrates with all Everest Form Add-Ons
  • Quick and easy to embed in any page or post on your website

How Does the Hospital Admission/Patient Intake Form Template Work? 

Our Patient Intake/Hospital Admission form is meant to enable doctors to easily gather thorough patient information. It guarantees customized and effective treatment by helping you grasp every patient's medical background and present needs. 

  • Personal Information: Collect vital details like the patient’s name, email, gender, date of birth, contact number, marital status, and address to create a complete patient profile. 
  • Reason for Visit: Patients can select the purpose of their visit, whether it's for a Routine Checkup, Illness, Injury, or other reasons, helping you prioritize and tailor care. 
  • Symptoms: If the visit is due to illness, patients can list their symptoms, helping you prepare for their assessment by the doctor. 
  • Past Medical History & Medications: Collect information on any significant medical history, allergies, and current medications to give the healthcare provider a full picture of the patient's health. 
  • Surgery History: If applicable, patients can provide details of any major surgeries they've had in the last 5 years to help assess ongoing health concerns. 
  • Emergency Contact: In emergencies, gather details about the patient’s guardian or emergency contact, including their relationship to the patient, contact number, and address. 
  • Privacy & Consent: Patients will confirm their agreement to the hospital's privacy policy and terms & conditions, ensuring all patient data is handled securely. 

This form ensures you have all the necessary details to provide accurate, safe, and personalized healthcare from when a patient walks in. 

How Do You Add Hospital Admission Form to Your Website?

You’ll need Everest Forms Pro to access all the fields in this form. Adding this Hospital Admission Form to your website is quick and easy. Just follow these steps:

  1. Navigate to Plugins >> Add New in your WordPress dashboard.
  2. Search for Everest Forms, then click Install and Activate.
  3. Once activated, go to Everest Forms >> Add New, select the Hospital Admission Form template.
  4. Customize the form as needed. Then, use the generated shortcode to embed the form on your desired page

If you need further assistance, watch this video tutorial to see exactly how to add one of these forms to your website. 

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