Client intakeClinics & physiotherapy

Physiotherapy intake form

Before a first session, a physiotherapist mainly needs to know where the problem is, how long it has been going on and whether the patient has a referral. This form asks those questions, plus an optional one about what the patient wants to get back to doing, and the days that suit them. That's enough to plan the session and match the right therapist without asking for a full medical history.

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What's in this template

Every field can be renamed, reordered, made optional or removed in the form builder.

  • Where do you have pain or problems?Multiple choice · Required
  • How long have you had it?Dropdown · Required
  • Do you have a referral or prescription?Single choice · Required
  • What would you like to get back to doing? (optional)Long answer · Optional
  • Which days suit you?Multiple choice · Required
  • Full nameShort answer · Required
  • Phone numberPhone · Required
  • EmailEmail · Required
  • ConsentCheckbox · Required

How to use this template

  1. Open it in your dashboardSelect “Use this template”. If you don't have an account yet, sign up first; the form opens right after.

  2. Make it yoursChange the questions, options, colours and the thank-you message in the form builder, then save.

  3. Share it and get submissionsShare the form's link or link to it from your website. Each submission is emailed to you and saved in your dashboard.

Tips for this form

  • Rename the body areas or add your specialisms, such as sports injuries or rehab after surgery, as extra options.
  • If you work with referrals, add a short paragraph explaining what patients should bring to their first session.
  • Remove Saturday from the preferred days if you're closed, or add Sunday if you're open.
  • Turn on the auto-responder so patients get an email saying you'll be in touch to arrange a time.

Running a business like this? See how Zotview sets up the website, booking and forms for Clinics and practices.

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Questions about this template

Does the form ask for a diagnosis?

No. It asks where the problem is, how long it has lasted and what the patient wants to achieve. The assessment happens in the session; the form only helps you prepare and plan.

Why ask whether there's a referral?

In many places a referral or prescription affects how treatment is paid for, so it helps to know before the first appointment. If it doesn't matter for your practice, delete the question in the builder.

Can patients choose a fixed time slot?

Not with this form: patients give their preferred days and you agree a time with them. If you'd like patients to pick from your real free slots, use Zotview's online booking system.

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