Free tool
Patient registration form format for clinics. For the front desk, with a DPDP notice.
Free patient registration form for Indian clinics: +91 mobile, family on one number, ABHA, emergency contact, a DPDP notice and WhatsApp consent. A5 or A4.
Form
Leave patient fields empty to print a blank pad for the front desk. The Hindi text has been written for this form; read it once before you use it.
Data contact (printed in the notice)
Patient (optional)
Clinic
Logo
Clinic logo only; a photograph of yourself on a letterhead is barred by clause 6.1.2. PNG or JPG, stays in this browser.
Doctor
Layout
What the notice has to say, and when the DPDP duties start, is in our DPDP guide for clinics.
Add the clinic name to print.
Everything you type is kept only in this browser on this device and is never sent to Vitels. It is not encrypted and anyone using this browser can see it, so press Clear after printing on a shared computer. In the print window choose “Save as PDF” for a file.
Clinic name
Patient registration form / रोगी पंजीकरण फ़ॉर्म
Patient / रोगी
Male / पुरुष
Female / महिला
Other / अन्य
Other family members on this number / इस नंबर पर परिवार के अन्य सदस्य
Address / पता
Emergency contact / आपातकालीन संपर्क
Notice and consent / सूचना और सहमति
The clinic collects the details on this form (name, age or date of birth, sex, mobile number, family members on that number, address, occupation, ABHA number if you give it and emergency contact) to register you, keep your treatment record and contact you about your visits. To see or correct your details, withdraw a consent below or raise a complaint, contact the front desk. If you are not satisfied with the reply, you may complain to the Data Protection Board of India.क्लिनिक इस फ़ॉर्म की जानकारी (नाम, आयु या जन्म तिथि, लिंग, मोबाइल नंबर, उस नंबर पर परिवार के सदस्य, पता, व्यवसाय, ABHA नंबर (यदि आप दें) और आपातकालीन संपर्क) आपका पंजीकरण करने, आपके इलाज का रिकॉर्ड रखने और आपकी विज़िट के बारे में आपसे संपर्क करने के लिए लेता है। अपनी जानकारी देखने या सुधारने, नीचे दी गई सहमति वापस लेने या शिकायत करने के लिए रिसेप्शन से संपर्क करें। जवाब से संतुष्ट न होने पर आप भारत के डेटा संरक्षण बोर्ड (Data Protection Board of India) में शिकायत कर सकते हैं।I agree to receive my token number and visit updates on WhatsApp and SMS at the mobile number above.मैं ऊपर दिए मोबाइल नंबर पर WhatsApp और SMS से अपना टोकन नंबर और विज़िट से जुड़ी जानकारी पाने के लिए सहमत हूँ।
I agree to receive follow-up reminders from the clinic on WhatsApp and SMS.मैं क्लिनिक से WhatsApp और SMS पर फ़ॉलो-अप रिमाइंडर पाने के लिए सहमत हूँ।
Preview at reduced size. Prints at full A4.
What the DPDP Act and the conduct regulations ask of a registration form
The Digital Personal Data Protection Act, 2023 and its 2025 Rules set what a clinic tells a patient when it collects their details. The 2002 conduct regulations set the record those details start.
- DPDP Act 2023, section 5(1)
A notice with every consent request
Every request for consent shall be accompanied or preceded by a notice telling the person the personal data and the purpose it will be processed for, how to withdraw consent and use the grievance process, and how to complain to the Data Protection Board. The box at the foot of the form is that notice.
- DPDP Rules 2025, G.S.R. 846(E), rule 3
What the notice must list
The notice has to be understandable on its own and give, in clear and plain language, at the minimum an itemised description of the personal data and the specified purpose, plus the means to withdraw consent, exercise rights and complain to the Board. The form lists each field it collects by name.
- DPDP Act 2023, section 6(1) and 6(4)
One tick per purpose, withdrawn as easily
Consent shall be free, specific, informed, unconditional and unambiguous with a clear affirmative action, for the specified purpose and limited to the data it needs. It can be withdrawn at any time, as easily as it was given. So the WhatsApp and SMS ticks are separate, printed empty, and withdrawn at the desk.
- DPDP Act 2023, sections 5(3) and 6(3)
English or a scheduled language, and a contact
The notice and the consent request must be available in English or any language in the Eighth Schedule to the Constitution, and the request must give the contact details of the person authorised to answer the patient. Hindi is printed beside English, and the notice names your data contact.
- G.S.R. 843(E), 13 Nov 2025; DPDP Act, section 3(a)
The notice duties start on 13 May 2027
Sections 3 to 5, most of section 6 and sections 7 to 10 come into force eighteen months after the commencement notification of 13 November 2025. The Act covers data collected digitally and data collected on paper and digitised later, so a paper form typed into software is in scope.
- IMC Regulations 2002, regulations 1.3.1, 1.3.2 and Appendix 3
The record starts at registration
Regulation 1.3.1 asks for records in the Appendix 3 format, which opens with name, age, sex, address, occupation and date of first visit. It is written for indoor patients, but it is the only medical record format in the regulations. Regulation 1.3.2 asks for copies within 72 hours of a request. Taking these fields at the desk starts that record.
What the front-desk registration form collects
In the order they appear on the printed form. Each item is also named in the notice, as rule 3 of the DPDP Rules asks.
Clinic letterhead, registration number and date
Full name of the patient
Age, or date of birth if the patient knows it
Sex, as a tick
Mobile number, with +91 printed
Other family members already registered on the same number, so the desk picks the right person next time
Address and occupation, the Appendix 3 fields
ABHA number, only if the patient wants to give it; the line can be removed
Emergency contact: name, relationship and mobile
The notice: what is collected, why, and whom to contact to see, correct or withdraw
Separate, empty ticks for token and visit messages, and for follow-up reminders, on WhatsApp and SMS
A line that the ticks are optional and can be withdrawn at the desk
Signature of the patient, or of a parent or guardian for a patient under 18, with the date
Registration at the desk, by mobile number
In Vitels the front desk types the mobile number, picks the right family member or adds a new one, and the patient gets their token on WhatsApp and SMS. Registration notices print in English and Hindi. New registration needs a connection; the queue and billing work offline. Vitels does not link ABHA.
Straight answers
What should a patient registration form contain?
A sensible minimum is the identifying fields that open the Appendix 3 medical record: name, age, sex, address, occupation and date of first visit, plus a mobile number and an emergency contact. Once the DPDP notice duties start, add a notice that lists those fields and their purpose, the contact for data requests, and separate consent ticks for any messages.
Do I need consent to send the token number on WhatsApp?
Section 7(a) of the DPDP Act allows processing for the purpose a person voluntarily gave the data for, unless they said no. Section 6(10) puts the burden of proving notice and consent on the clinic where consent is the basis. A separate tick on a signed form records what the patient agreed to, which is simpler to show than an inference.
Is the ABHA number required on a clinic registration form?
This form treats it as optional, and you can remove the line. Vitels does not create or link ABHA numbers, so an ABHA number written here stays on paper. Ask for it only if your clinic uses it for something; under section 6(1), consent covers only the data necessary for the purpose you state.
When do the DPDP rules on notice and consent apply to clinics?
The commencement notification G.S.R. 843(E) brings sections 3 to 5, most of section 6 and sections 7 to 10 into force eighteen months after 13 November 2025, which is 13 May 2027. The Act covers data collected on paper and digitised later, so a clinic that types registration forms into software is covered.
Who signs the form for a child?
The DPDP Act defines a child as anyone who has not completed eighteen years, and section 9(1) asks for verifiable consent of the parent or lawful guardian before processing a child's personal data. The signature line on this form reads patient, or parent or guardian if under 18.
Does the tool store patient details?
Patient details stay in this browser session only, unencrypted, on this device; closing the tab or pressing Clear removes them. The letterhead is kept for next time and shared with the other Vitels tools. Nothing is sent to Vitels. You can also print a blank stack for patients to fill by hand.
This tool only lays out a form and a notice. The clinic decides what it collects and why, and is responsible for using the data only for the purposes on the form. The Hindi text was written for this form; have it read by someone fluent before relying on it. This page summarises the Digital Personal Data Protection Act, 2023, the DPDP Rules, 2025 and the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002; it is general information, not legal advice. Your state rules may ask for more.
Related tools and pages
DPDP Act for clinics
The dated checklist: notice, consent, security, breach reporting and retention under the Act and the 2025 Rules.
OpenConsent form maker
Procedure consent in English and Hindi, kept separate from consent to use personal data.
OpenOPD token system
Paper tokens, a display or WhatsApp: how each works at a small clinic's desk.
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