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Patient Intake Form

Patient Intake Form Template for Switzerland

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Key Requirements PROMPT example:

Patient Intake Form

"I need a comprehensive Patient Intake Form in German and French for my new dental practice opening in Zurich in March 2025, with specific sections for dental history and orthodontic treatment consent."

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Document background
The Patient Intake Form is a fundamental document used across Swiss healthcare facilities to establish the initial medical relationship between healthcare providers and patients. It serves as a comprehensive tool for collecting essential patient information, including personal details, medical history, insurance information, and necessary consents. The form must comply with Swiss federal regulations, particularly the Federal Act on Data Protection (FADP/DSG) and healthcare-specific legislation. This document is typically completed before the first medical consultation and serves as a basis for creating the patient's medical record. It includes sections for emergency contacts, current medications, allergies, and previous medical conditions, while incorporating mandatory privacy notices and consent declarations as required by Swiss law.
Suggested Sections

1. Personal Information: Basic patient details including name, date of birth, address, contact information, and identification numbers

2. Insurance Information: Health insurance details, policy numbers, and coverage information as required by Swiss healthcare system

3. Emergency Contact Details: Contact information for next of kin or emergency contacts

4. Medical History: Current health conditions, past surgeries, chronic illnesses, and medications

5. Family Medical History: Relevant family health conditions and genetic predispositions

6. Current Medications: List of current medications, dosages, and supplements

7. Allergies and Reactions: Documentation of known allergies and adverse reactions

8. Data Protection Notice: Information about how patient data will be processed and stored in accordance with Swiss law

9. Consent Declarations: Patient's consent for treatment, data processing, and information sharing

10. Financial Responsibility: Agreement regarding payment terms and insurance billing procedures

Optional Sections

1. Specialty-Specific Questions: Additional questions specific to certain medical specialties (e.g., gynecology, pediatrics, orthopedics)

2. Research Participation: Optional consent for participation in medical research or clinical trials

3. Language Preferences: Preferred language for communication and need for translation services

4. Digital Communication Consent: Opt-in for email or SMS communications and appointment reminders

5. Alternative Medicine History: Information about complementary or alternative medicine treatments

6. Lifestyle Information: Optional questions about diet, exercise, smoking, alcohol consumption

7. Travel History: Recent travel information, relevant for infectious disease monitoring

8. Vaccination Record: Detailed vaccination history section for practices requiring this information

Suggested Schedules

1. Privacy Policy: Detailed explanation of the practice's privacy policy and data protection measures

2. Patient Rights Document: Comprehensive information about patient rights under Swiss law

3. Fee Schedule: List of common procedures and associated costs

4. Insurance Information Guide: Guide explaining insurance billing procedures and covered services

5. Medical Records Release Form: Standard form for authorizing release of medical records

6. Prescription Refill Policy: Information about the practice's prescription refill procedures

Authors

Alex Denne

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

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alex.den.21@genieai.co
Relevant legal definitions
Healthcare Provider
Medical Practice
Patient
Legal Representative
Emergency Contact
Medical History
Current Medication
Chronic Condition
Pre-existing Condition
Health Insurance Provider
Insurance Policy
Premium
Deductible
Co-payment
Personal Data
Sensitive Health Data
Data Processing
Electronic Health Record
Medical Confidentiality
Informed Consent
Treatment Plan
Medical Emergency
Prescription Medication
Over-the-Counter Medication
Adverse Reaction
Privacy Notice
Data Protection Officer
Medical Records
Healthcare Services
Billing Information
Relevant Industries

Healthcare

Medical Services

Dental Care

Mental Health

Alternative Medicine

Pharmaceutical

Insurance

Healthcare Technology

Medical Research

Relevant Teams

Medical Administration

Front Desk

Clinical Operations

Compliance

Legal

Data Protection

Quality Assurance

Patient Services

Records Management

Insurance Processing

Relevant Roles

Medical Doctor

Dentist

Psychiatrist

Nurse Practitioner

Clinical Administrator

Medical Office Manager

Healthcare Compliance Officer

Medical Records Manager

Practice Manager

Healthcare Data Protection Officer

Medical Assistant

Reception Coordinator

Insurance Coordinator

Clinical Director

Quality Assurance Manager

Industries
Federal Act on Data Protection (FADP/DSG): This law governs the protection of personal data, including sensitive health data. It's particularly relevant for patient information collection and storage.
Federal Act on Electronic Patient Records (EPRA): Regulates the implementation and management of electronic patient records, including requirements for data security and access rights.
Swiss Civil Code (Art. 27-28): Provisions regarding personal rights and protection of personality, which include medical privacy and bodily integrity.
Federal Act on Research involving Human Beings (HRA): Relevant for any potential research use of patient data and ensuring proper consent procedures.
Federal Act on Medical Professions (MedBG): Sets standards for medical practice and professional obligations regarding patient care and documentation.
Federal Act on Health Insurance (KVG): Relevant for billing and insurance information collection in the intake form.
Swiss Criminal Code (Art. 321): Governs medical confidentiality and professional secrecy obligations.
General Data Protection Regulation (GDPR): While not Swiss law, it may be relevant if dealing with EU patients or data transfer to EU countries.
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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