Templates · Free template · Intake
Client Intake Form Template
A general-purpose client intake form that works for most health and wellness practices, and links to the specialty versions for aesthetics, physiotherapy, chiropractic, massage therapy, counselling and medical history.
What every intake form should collect
Contact details and an emergency contact; the reason for the visit in the client's own words; relevant health history, medications and allergies; anything that changes what you can safely do; the client's goals; and consent to assessment, treatment and communication.
Ask only for what you'll use. Every extra question is information you have to protect, and Canadian privacy law (PIPEDA, or your province's health privacy act) expects you to collect what's necessary for the purpose.
Specialty intake forms
Disciplines need different detail. The specialty templates add what each practice actually needs: skin history and Fitzpatrick type for aestheticians, injury and funding source for physiotherapy, red flags for chiropractic, pressure and areas to avoid for massage, and safety questions for counselling. They're linked at the bottom of this page.
Client Intake Form
Client
Address and emergency contact
Reason for visit
Health history
Consent
Signatures
Template from zdrovia.ca/templates/client-intake-form-template/ · Have clients fill and sign it on their phone, free, at zdrovia.ca · Review with your medical director, regulatory college guidance, and insurer before use.
Send this form before the appointment instead of printing it
Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for multidisciplinary clinics.
Frequently asked questions
What should be on a client intake form?
Contact and emergency details, the reason for the visit, health history, medications and allergies, the client's goals, and consent to treatment, communication and the handling of their information.
Can clients fill in intake forms online?
Yes, and most clinics now send them before the first appointment so the answers can be reviewed in advance and filed to the client's record automatically.
How long should I keep intake forms?
As long as the rest of the clinical record. Retention periods are set by your regulatory college or provincial rules, commonly 10 years from the last visit for adults.
Related
This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.