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Basic Intake Form

Basic Intake Form Template for Nigeria

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Key Requirements PROMPT example:

Basic Intake Form

"I need a Basic Intake Form for my new private medical practice in Lagos, which will open in March 2025, that includes sections for medical history and insurance details while complying with Nigerian healthcare privacy regulations."

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Document background
The Basic Intake Form serves as a fundamental document for initial client engagement across various sectors in Nigeria. It is designed to collect essential information from new clients while ensuring compliance with the Nigeria Data Protection Regulation (NDPR) 2019 and other relevant Nigerian laws. This document should be used at the first point of contact with new clients or when updating existing client information. The Basic Intake Form includes sections for personal information, contact details, consent declarations, and service-specific requirements, with optional modules that can be activated based on the specific service context. It is structured to protect both the service provider and client while ensuring transparent data collection practices and clear documentation of the client-provider relationship.
Suggested Sections

1. Personal Information: Basic client details including full name, date of birth, nationality, and contact information

2. Contact Details: Comprehensive contact information including physical address, email, phone numbers, and preferred contact method

3. Identification Details: Government-issued ID information, type of ID provided, and ID number

4. Emergency Contact Information: Details of person(s) to contact in case of emergency

5. Data Protection Notice: Statement on how personal information will be collected, used, and protected in compliance with NDPR

6. Consent Declaration: Client's explicit consent for data collection and processing

7. Signature and Date: Space for client signature and date of completion

Optional Sections

1. Medical Information: Optional section for collecting relevant medical history or conditions when required for specific services

2. Employment Details: Optional section for collecting employment status and information when relevant to service provision

3. Financial Information: Optional section for collecting banking or payment details when required for billing purposes

4. Service-Specific Requirements: Optional section for collecting information specific to particular services being sought

5. Guardian Information: Optional section for cases involving minors or individuals requiring legal guardianship

Suggested Schedules

1. Schedule A - Required Documents Checklist: List of additional documents required to be submitted with the intake form

2. Schedule B - Terms and Conditions: Detailed terms and conditions regarding the use and processing of provided information

3. Schedule C - Privacy Policy: Detailed privacy policy and data protection measures in compliance with NDPR

4. Appendix 1 - Service-Specific Forms: Additional forms specific to particular services being requested

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

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant Industries

Healthcare

Legal Services

Financial Services

Education

Professional Services

Real Estate

Insurance

Consulting

Social Services

Hospitality

Relevant Teams

Reception

Administration

Client Services

Operations

Compliance

Data Protection

Customer Relations

Business Development

Front Office

Human Resources

Relevant Roles

Client Services Manager

Administrative Assistant

Intake Coordinator

Office Manager

Customer Relations Officer

Compliance Officer

Data Protection Officer

Operations Manager

Front Desk Executive

Service Coordinator

Business Development Manager

Human Resources Manager

Industries
Nigeria Data Protection Regulation (NDPR) 2019: Regulates the collection, storage, and processing of personal data. Essential for ensuring compliance in data collection through intake forms.
Nigerian Contract Law (derived from Common Law): Governs the formation and validity of contracts, including requirements for offer, acceptance, consideration, and capacity to contract.
Consumer Protection Council Act: Provides protection for consumers in terms of information disclosure and fair business practices when collecting client information.
Evidence Act 2011: Governs the admissibility of electronic documents and digital signatures, relevant for electronic intake forms.
Freedom of Information Act 2011: Relevant for transparency in data collection and usage, particularly when dealing with public institutions.
Cybercrimes (Prohibition, Prevention, etc.) Act 2015: Ensures security measures in electronic data collection and storage, protecting against unauthorized access and cyber threats.
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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