Use This Template

New Patient Registration - Children

Use our free patient registration form template to collect necessary information from prospective patients.

This template includes sections for basic child information as well as parent/guardian, demographic, insurance, and emergency contact information. We also included a section for your staff to mark when the registration information has been added to the patient’s medical file. Using our Entries page and workflow statuses, your staff can easily track if each registration has been added to your internal system.

This version of our patient registration form is created for children and pediatric patients. We have an adult version of the patient registration template available as well.

All data collected can be made HIPAA compliant with our Enterprise plan after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure at rest and in transit.

Easily customize the template for your practice by adding, removing, and editing fields to fit your needs. Quickly brand it with your logo and style using our Organization Theme feature. It’s also easy to embed your form directly on your practice’s website!

New Patient Registration - Children

Use our free new patient registration form template to collect information from prospective patients.



  • Public
  • Internal


  • Incomplete
  • Submitted
  • Processed