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Patient Intake Form

Patient Intake Form Template for Indonesia

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Key Requirements PROMPT example:

Patient Intake Form

"I need a bilingual (Indonesian-English) Patient Intake Form for my new private clinic opening in Jakarta in March 2025, with special emphasis on international patient documentation and travel history tracking."

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Document background
The Patient Intake Form is a crucial document used across healthcare facilities in Indonesia to establish the initial medical record for new patients or update existing patient information. This form is designed in accordance with Indonesian healthcare regulations, particularly Law No. 29 of 2004 on Medical Practice and related healthcare administration requirements. It serves as a comprehensive tool for collecting patient demographics, medical history, insurance information, and necessary consents, while ensuring compliance with Indonesian data protection laws. The form is typically completed during a patient's first visit to a healthcare facility or when significant updates to patient information are needed. It includes sections for personal identification, medical history, emergency contacts, and consent forms, all structured to meet both clinical needs and legal requirements under Indonesian jurisdiction.
Suggested Sections

1. Patient Personal Information: Basic demographic information including full name, ID number, date of birth, gender, and contact details

2. Emergency Contact Information: Details of primary and secondary emergency contacts including relationship to patient

3. Insurance Information: Health insurance details including policy number, provider, and coverage type

4. Medical History: Patient's past medical conditions, surgeries, hospitalizations, and chronic conditions

5. Current Medications: List of current medications, dosages, and frequency

6. Allergies and Reactions: Known allergies to medications, foods, or environmental factors

7. Family Medical History: Relevant family medical history focusing on hereditary conditions

8. Consent for Treatment: Legal consent for medical treatment and procedures

9. Privacy Policy Acknowledgment: Acknowledgment of understanding regarding how personal health information will be used and protected

10. Financial Responsibility: Agreement to financial obligations and payment terms

Optional Sections

1. Language Preference: Preferred language for communication and need for interpreter services, relevant for multicultural areas of Indonesia

2. Religious Preferences: Religious considerations that may affect medical treatment, particularly relevant in Indonesia's religious context

3. Advance Directives: Optional section for patients who wish to specify advance medical directives

4. Traditional Medicine History: Information about use of traditional Indonesian medicine or alternative treatments

5. Special Needs Accommodation: Any special requirements for physical or cognitive disabilities

6. Travel History: Recent travel history, particularly relevant during infectious disease outbreaks

7. Occupational Health Information: Work-related health risks or concerns, relevant for employed patients

Suggested Schedules

1. Medical History Details Form: Detailed questionnaire about specific medical conditions and past treatments

2. Medication List Template: Structured format for listing current and past medications

3. Insurance Information Attachment: Format for attaching insurance card copies and related documentation

4. Privacy Policy Document: Detailed privacy policy in accordance with Indonesian data protection laws

5. Patient Rights and Responsibilities: Comprehensive list of patient rights and responsibilities under Indonesian healthcare laws

6. Payment Terms and Conditions: Detailed financial policies and payment arrangements

Authors

Alex Denne

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

alex.den.21@genieai.co
Relevant legal definitions






























Clauses




















Relevant Industries

Healthcare

Medical Services

Hospital Administration

Insurance

Data Protection

Legal Compliance

Public Health

Primary Care

Specialist Care

Emergency Services

Relevant Teams

Admissions

Patient Registration

Medical Records

Compliance

Legal

Patient Services

Quality Assurance

Clinical Operations

Front Office

Data Management

Insurance Coordination

Relevant Roles

Medical Director

Hospital Administrator

Clinical Director

Admissions Officer

Front Desk Coordinator

Medical Records Manager

Compliance Officer

Data Protection Officer

Healthcare Facility Manager

Patient Services Coordinator

Legal Counsel

Quality Assurance Manager

Head Nurse

Primary Care Physician

Registration Specialist

Insurance Coordinator

Industries








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, 聽Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination, 聽Severance Pay, Governing Law, Entire Agreemen

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