Patient Enrollment Form Template

When it comes to health, it becomes immensely important for the health care service as well as the providers to know all the details about the patient. Information as simple as the patient’s gender can give lots of clues about the disease, its diagnosis, and appropriate management. This would otherwise make it almost impossible to treat the patient at all or adequately treat them.

Information about the patient was previously collected in the form of manual data forms, which was a little more time-consuming and required too much energy. New patient enrollment forms are a new way to efficiently enter all the details of the patient and use the same information for reference in the future.

Patient Enrollment Form

If you are a healthcare facility and interested in the new patient enrollment form, you need to know some basic requirements while finalizing the form. Let’s investigate the details and break them down one by one.


As mentioned, the patient’s basic data can be simple information for anyone else. But in the field of healthcare, it means so much because there are many diseases, and their treatment is age- and gender-specific. It is sometimes even profession-specific.

So, any new patient enrollment form will begin with the name, age, and gender of the patient. You can simply provide the details while asking for them. Then come the contact number and address and the kinship rows. It is important to follow the patient for future health follow-up and update them. In case of an emergency, the next emergency contact is also needed to make the emergency treatment even more hassle-free. The marital status of the patient is also added in the section ‘introduction’.

History related to health

The patient’s health history then becomes the priority when using the new patient enrollment form. Once we are done with the basic information, a couple of rows and columns must be dedicated to the past medical and surgical history of the patient. We need to know in a little detail if there is any significant history.

We also want to know about the history of smoking, addiction, allergies, and the use of any drug of any kind, now or in the past. The urinary and bowel habits are also important to know because they also help in reaching a diagnosis and assessing if the quality of life is affected by the current illness.

Insurance details

Health insurance details are an integral part of any new patient enrollment form. The health insurance date of issuance and expiration date. The maximum limit of health insurance and other details are also mentioned in this section. We also mention the type of insurance with which we know about medical coverage for surgery, accidents, childbirth, and outpatient limits. Health insurance for the family members, if any, is also included in the same section.

The last section of the new patient enrollment form includes the signatures of the person who fills out the form and is also signed by the patient.

Simple form [MS Word]

Patient enrollment form template

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