Template · Clinic

Chiropractor new patient intake form

Collect the brief, the files and the health notes before the first visit — one link, one chat, nothing to chase.

Align Chiropractic · sample business
a chiropractor used to demonstrate the intake template

What this template is for

Someone woke up with a locked back and wants to know the first slot today and what to expect on a first visit. This intake flow asks the right things first: the patient chooses what they need, answers a handful of questions and attaches a file, and you arrive at the first appointment already prepared.

You get the complaint, how long it has lasted and the preferred time before you pick up the phone. Because it is a chat, you can ask the one follow-up you always need without a new form or a phone call, and the patient gets an email copy.

Send it as a link after the first contact, put it on your website’s "work with us" page, or use it as the link in your bio.

What it asks

The first thing a customer sees: “Welcome — what brings you in?”

First visit
- Your name — text, required
- Email — text, required
- Phone number — text, required
- What brings you in? — long text, required
- When would you like to come in? — date
- Attach a file — file upload
Shows a confirmation message
Adjustment
- Your name — text, required
- Email — text, required
- Phone number — text, required
- What brings you in? — long text, required
- When would you like to come in? — date
- Attach a file — file upload
Shows a confirmation message
Back pain
- Your name — text, required
- Email — text, required
- Phone number — text, required
- What brings you in? — long text, required
- When would you like to come in? — date
- Attach a file — file upload
Shows a confirmation message
Headaches
- Your name — text, required
- Email — text, required
- Phone number — text, required
- What brings you in? — long text, required
- When would you like to come in? — date
- Attach a file — file upload
Shows a confirmation message

How to use it

Tap "Use this template" — it copies into your free account.
Adjust the services and the questions; remove what you do not need, add the one thing you always ask.
Send the link to new patients or embed it on your site.
Read each intake in your inbox, reply in the thread, and book the first appointment from there.

Questions

Can patients upload documents?

Yes. The file field accepts documents, images and PDFs from any device; they arrive with the answers in the chat.

Is the information private?

Only you and the people you invite to your account see the answers. The patient sees their own conversation. See the privacy policy for the details.

Can I send it to someone directly?

Yes. Every flow has a share link you can paste in an email or a message; the answers land in the same inbox as everything else.

Does it replace my CRM?

It replaces the intake form and the back-and-forth. On paid plans each contact becomes a CRM entry with the conversation attached, and you can forward answers to other tools.

Every plan runs this template. Pay for volume, not features.

Free$025 bookings / mo · 2 widgets

Standard$9.99100 bookings / mo · 5 widgets

Premium$19.99500 bookings / mo · unlimited widgets

Pro$79.99Unlimited · leads · API

EnterpriseCustomUnlimited

See all plans

Start with the chiropractor new patient intake form

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Chiropractor new patient intake form

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What this template is for

What it asks

How to use it

Questions

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Every plan runs this template. Pay for volume, not features.

Start with the chiropractor new patient intake form