Patient Intake Form

Patient Intake Form Template for Philippines

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Key Requirements PROMPT example:

"I need a Patient Intake Form for my new dental clinic in Manila, opening in March 2025, that includes specific sections for dental history and focuses on collecting information from both adult patients and parents of minor patients, with enhanced data privacy provisions for compliance with Philippine regulations."

Document background

The Patient Intake Form is a crucial document required by healthcare providers in the Philippines to initiate patient care and maintain accurate medical records. This form must comply with multiple Philippine regulations, including the Data Privacy Act of 2012, the Philippine Medical Act, and the Patient's Rights and Obligations Act. It serves as the primary tool for collecting patient demographic information, medical history, insurance details, and necessary consents for treatment. The form is typically completed upon a patient's first visit to a healthcare facility or when establishing care with a new provider. It includes sections for emergency contacts, current medications, allergies, and past medical history, while also incorporating required privacy notices and consent declarations. The document is designed to protect both patient and provider interests while ensuring compliance with Philippine healthcare documentation requirements.

Suggested Sections

1. Patient Personal Information: Basic demographic information including full name, date of birth, address, contact details, and government-issued ID numbers

2. Emergency Contact Information: Details of primary and secondary emergency contacts including relationship to patient

3. Insurance Information: Health insurance details, PhilHealth number, and other relevant insurance coverage information

4. Medical History: Current medical conditions, past surgeries, chronic illnesses, and family medical history

5. Current Medications: List of current medications, dosages, and allergies to medications

6. Privacy Notice and Data Protection: Statement of compliance with Data Privacy Act and explanation of how patient information will be used and protected

7. Consent for Treatment: General consent for medical treatment and acknowledgment of financial responsibility

8. Patient Rights and Responsibilities: Overview of patient rights under Philippine law and responsibilities in the healthcare setting

9. Signature and Authentication: Patient signature, date, and witness signatures where required

Optional Sections

1. Mental Health Assessment: Additional section for mental health screening, required when facility provides mental health services

2. Reproductive Health History: Specific section for gynecological/reproductive health services, used in relevant medical settings

3. Dental History: Specific section for dental practices, including dental work history and concerns

4. Traditional Medicine Use: Section for declaring use of traditional Filipino medicine or alternative treatments

5. COVID-19 Screening: Temporary section for pandemic-related screening and contact tracing

6. Specialized Care Requirements: Additional section for patients requiring special accommodation or care arrangements

7. Language and Cultural Preferences: Optional section for facilities serving diverse populations to note language preferences and cultural considerations

Suggested Schedules

1. Schedule A - Notice of Privacy Practices: Detailed explanation of the facility's privacy policies and patient rights under the Data Privacy Act

2. Schedule B - Financial Policies: Detailed explanation of billing practices, payment policies, and insurance processing procedures

3. Schedule C - Facility Policies: Overview of relevant facility policies including visiting hours, appointment scheduling, and emergency procedures

4. Appendix 1 - Medical History Details: Detailed medical history questionnaire for comprehensive health assessment

5. Appendix 2 - Medication List Template: Structured template for listing current medications and supplements

6. Appendix 3 - Consent Forms: Collection of specific consent forms for various procedures and treatments

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Hospitals

Clinics

Dental Practices

Mental Health Services

Allied Health Services

Medical Insurance

Healthcare Administration

Relevant Teams

Medical Records

Admissions

Patient Services

Compliance

Quality Assurance

Risk Management

Data Protection

Front Desk

Administrative Support

Legal

Relevant Roles

Medical Director

Physician

Nurse

Hospital Administrator

Clinic Manager

Medical Records Officer

Data Privacy Officer

Healthcare Compliance Officer

Patient Services Coordinator

Admissions Officer

Medical Secretary

Healthcare Facility Manager

Quality Assurance Manager

Risk Management Officer

Patient Relations Officer

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Authors

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